1558476887 NPI number — BRIAN S DODD PAC

Table of content: BRIAN S DODD PAC (NPI 1558476887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558476887 NPI number — BRIAN S DODD PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DODD
Provider First Name:
BRIAN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1558476887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 SHARON AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENOIR
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28645-4326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-758-7091
Provider Business Mailing Address Fax Number:
828-758-7058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
232 SHARON AVE NW
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
LENOIR
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28645-4326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-758-7091
Provider Business Practice Location Address Fax Number:
828-758-7058
Provider Enumeration Date:
08/19/2006

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: 363A00000X , with the licence number:  PA331 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 0010-04342 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010030444 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010162910 . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 029674 . This is a "WA DEPARTMENT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PAF45 . This is a "BLUE CROSS OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: PAMD9 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 194498 . This is a "OMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 806341400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K248 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com