1306876818 NPI number — JILL A ENDICOTT NP

Table of content: JILL A ENDICOTT NP (NPI 1306876818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306876818 NPI number — JILL A ENDICOTT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENDICOTT
Provider First Name:
JILL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1306876818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64803-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-347-6400
Provider Business Mailing Address Fax Number:
417-347-6404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3202 MCINTOSH CIR
Provider Second Line Business Practice Location Address:
SUITE LL03
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-6400
Provider Business Practice Location Address Fax Number:
417-347-6404
Provider Enumeration Date:
07/03/2006

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: 363L00000X , with the licence number:  2004019593 , 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: 192713 . This is a "ANTHEM" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00175249 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200034570A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200265670A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 429313307 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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