1386830966 NPI number — JULIE MARIE BOYTIM RN, CRNA

Table of content: JULIE MARIE BOYTIM RN, CRNA (NPI 1386830966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386830966 NPI number — JULIE MARIE BOYTIM RN, CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYTIM
Provider First Name:
JULIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIGHT
Provider Other First Name:
JULIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386830966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1737 BRIARCREST DR 14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77802-2739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-776-4777
Provider Business Mailing Address Fax Number:
979-776-0588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2411 FOUNTAIN VIEW DR
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77057-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-620-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2007

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: 367500000X , with the licence number:  686777 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2104039 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00821827 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 191904502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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