1093896979 NPI number — JAMIE L DEHAN P.T.

Table of content: JAMIE L DEHAN P.T. (NPI 1093896979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093896979 NPI number — JAMIE L DEHAN P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEHAN
Provider First Name:
JAMIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1093896979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
294 NE TUDOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64086-5696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-554-6003
Provider Business Mailing Address Fax Number:
816-554-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
294 NE TUDOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEES SUMMIT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64086-5696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-554-6003
Provider Business Practice Location Address Fax Number:
816-554-6013
Provider Enumeration Date:
10/18/2006

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:  11-03611 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200417370A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00375646 . This is a "RETIRED RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200417370B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".