1093708950 NPI number — SUSAN M BEARDEMPHL PT

Table of content: SUSAN M BEARDEMPHL PT (NPI 1093708950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093708950 NPI number — SUSAN M BEARDEMPHL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEARDEMPHL
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093708950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10004 204TH AVE E
Provider Second Line Business Practice Location Address:
STE 3100
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-6539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-863-7510
Provider Business Practice Location Address Fax Number:
253-863-5970
Provider Enumeration Date:
08/25/2005

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: 225100000X , with the licence number:  PT00005235 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 650015277 . This is a "R/R MED" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8385510 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8930871 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 118317 . This is a "DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3822BE . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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