1205932712 NPI number — LOW BLUFFS EMERGENCY PHYSICIANS

Table of content: (NPI 1205932712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205932712 NPI number — LOW BLUFFS EMERGENCY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOW BLUFFS EMERGENCY PHYSICIANS
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:
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:
1205932712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
533 W NORTH AVE
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 N WESTWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-327-0275
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE/VICE PRESIDENT
Authorized Official Telephone Number:
800-732-1066

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 215535 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 516170 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".