1467450163 NPI number — JAY A SWEDBERG

Table of content: JAY A SWEDBERG (NPI 1467450163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467450163 NPI number — JAY A SWEDBERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWEDBERG
Provider First Name:
JAY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1467450163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6500 E 2ND ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82609-4338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-577-5100
Provider Business Mailing Address Fax Number:
307-234-1201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 E 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82609-4338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-577-5100
Provider Business Practice Location Address Fax Number:
307-234-1201
Provider Enumeration Date:
07/07/2005

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: 207Q00000X , with the licence number:  3305A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 19719 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 104351000 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 314127 . This is a "BC/BS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 611665900 . This is a "DEPT OF LABOR" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".