1528057387 NPI number — MR. TRACEY G WELLENDORF MD

Table of content: MR. TRACEY G WELLENDORF MD (NPI 1528057387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528057387 NPI number — MR. TRACEY G WELLENDORF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLENDORF
Provider First Name:
TRACEY
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1528057387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 766
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51401-0766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-792-4368
Provider Business Mailing Address Fax Number:
712-792-4351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 S CLARK ST
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
CARROLL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51401-3065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-792-4368
Provider Business Practice Location Address Fax Number:
712-792-2056
Provider Enumeration Date:
10/14/2005

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: 207Y00000X , with the licence number:  30594 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3124032 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5124032 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124032 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6124032 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2124032 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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