1558774810 NPI number — MS. AMANDA SHORT BS

Table of content: MS. AMANDA SHORT BS (NPI 1558774810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558774810 NPI number — MS. AMANDA SHORT BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORT
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BS
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:
1558774810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 MICAH DR
Provider Second Line Business Mailing Address:
DRAWER M
Provider Business Mailing Address City Name:
OLNEY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62450-4720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-395-4306
Provider Business Mailing Address Fax Number:
618-395-4507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 W HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROBINSON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62454-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-546-1021
Provider Business Practice Location Address Fax Number:
618-544-7892
Provider Enumeration Date:
06/04/2014

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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