1154326544 NPI number — RODNEY KENT VAN ANDEL M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154326544 NPI number — RODNEY KENT VAN ANDEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN ANDEL
Provider First Name:
RODNEY
Provider Middle Name:
KENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1154326544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75712-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:
903-593-7569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3203 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75771-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-266-4000
Provider Business Practice Location Address Fax Number:
903-882-7751
Provider Enumeration Date:
06/14/2005

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: 207Q00000X , with the licence number:  L7909 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X , with the licence number: L7909 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 138771100 . This is a "FIRSTCARE SOUTHWEST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00165779 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 166412003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K1901 . This is a "TEXAS BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 001 . This is a "TRICARE CANTON LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 002 . This is a "TRICARE LAKE PALESTINE LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 028 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PP10013213 . This is a "TEXAS WORKERS COMP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129375 . This is a "CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8V5495 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 166412001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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