1003079138 NPI number — MICHELE A NEDELKA MD

Table of content: MICHELE A NEDELKA MD (NPI 1003079138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003079138 NPI number — MICHELE A NEDELKA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEDELKA
Provider First Name:
MICHELE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003079138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 WATER ST
Provider Second Line Business Mailing Address:
SUITE J-100
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-3523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-257-3131
Provider Business Mailing Address Fax Number:
830-257-3161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 WATER ST
Provider Second Line Business Practice Location Address:
SUITE J-100
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-3523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-257-3131
Provider Business Practice Location Address Fax Number:
830-257-3161
Provider Enumeration Date:
07/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  0116020811 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: P7521 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)