1013243633 NPI number — BURGESS HEALTH CENTER

Table of content: (NPI 1013243633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013243633 NPI number — BURGESS HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURGESS HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BURGESS FAMILY CLINIC - SLOAN
Provider Other Organization Name Type Code:
3
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:
1013243633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 DIAMOND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONAWA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51040-1548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-423-2311
Provider Business Mailing Address Fax Number:
712-423-9199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 EVANS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLOAN
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51055-7748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-428-4100
Provider Business Practice Location Address Fax Number:
712-428-4102
Provider Enumeration Date:
11/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BEHNE
Authorized Official First Name:
CARL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
712-423-2311

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0634865 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com