1447250881 NPI number — JILLANA G. BURGESS

Table of content: JILLANA G. BURGESS (NPI 1447250881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447250881 NPI number — JILLANA G. BURGESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
JILLANA
Provider Middle Name:
G.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1447250881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/22/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 W WASHINGTON AVE
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
ARTESIA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88210-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-748-3305
Provider Business Mailing Address Fax Number:
505-748-3305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W WASHINGTON AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ARTESIA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88210-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-748-3305
Provider Business Practice Location Address Fax Number:
505-748-3305
Provider Enumeration Date:
07/28/2005

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: 111N00000X , with the licence number:  845 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 850327964 . This is a "LOVELACE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: N8814 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 850327964 . This is a "MAIL HANDLERS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 850327964 . This is a "CIGNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 850327964 . This is a "CIMARRON" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: K895 . This is a "BC/BS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 850327964 . This is a "HEALTHSMART" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com