1306931423 NPI number — IRON BRIDGE DIABETES & ENDO

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 1306931423 NPI number — IRON BRIDGE DIABETES & ENDO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRON BRIDGE DIABETES & ENDO
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:
1306931423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1135 E LAKEWOOD ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65810-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-879-6364
Provider Business Mailing Address Fax Number:
417-879-6368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 E LAKEWOOD ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65810-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-879-6364
Provider Business Practice Location Address Fax Number:
417-879-6368
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUDA
Authorized Official First Name:
RALPH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-879-6364

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 16610 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 460002667 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00266673 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000015170 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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