1124003322 NPI number — RHONDA S ALTHAGE MA

Table of content: RHONDA S ALTHAGE MA (NPI 1124003322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124003322 NPI number — RHONDA S ALTHAGE MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALTHAGE
Provider First Name:
RHONDA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACKWELL
Provider Other First Name:
RHONDA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124003322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 E SPRINGFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SULLIVAN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63080-1361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-541-9930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13160 COUNTY RD 3610
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. JAMES
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-265-3251
Provider Business Practice Location Address Fax Number:
573-265-2508
Provider Enumeration Date:
12/09/2005

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: 101Y00000X , with the licence number:  2003006346 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 496041625 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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