1548210628 NPI number — DR. ANGELA HALIBURDA D.O.

Table of content: DR. ANGELA HALIBURDA D.O. (NPI 1548210628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548210628 NPI number — DR. ANGELA HALIBURDA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALIBURDA
Provider First Name:
ANGELA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1548210628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 CAVIL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE PERE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54115-3772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-351-0289
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 32ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-1649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-230-7788
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2006

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: 207LP2900X , with the licence number:  48462 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43517300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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