1639167562 NPI number — DR. SHAUN G LENCKI MD

Table of content: DR. SHAUN G LENCKI MD (NPI 1639167562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639167562 NPI number — DR. SHAUN G LENCKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LENCKI
Provider First Name:
SHAUN
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
1639167562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65808-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-269-5712
Provider Business Mailing Address Fax Number:
417-269-7567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E PRIMROSE ST STE 360
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65807-5293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-269-4037
Provider Business Practice Location Address Fax Number:
417-269-6139
Provider Enumeration Date:
10/13/2005

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: 207VM0101X , with the licence number:  ME86568 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X , with the licence number: 2020007993 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 202013798 . This is a "TAX ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: N290176 . This is a "HEALTHEASE (MEDICIAD HMO)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 265903400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 62954 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5361051 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com