1669584603 NPI number — DR. JOHN C WIGGANS MD

Table of content: DR. JOHN C WIGGANS MD (NPI 1669584603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669584603 NPI number — DR. JOHN C WIGGANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIGGANS
Provider First Name:
JOHN
Provider Middle Name:
C
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:
1669584603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64184-3225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-633-1234
Provider Business Mailing Address Fax Number:
708-342-7100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3250 GORDONVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 358
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-5056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-331-3155
Provider Business Practice Location Address Fax Number:
573-331-5096
Provider Enumeration Date:
08/31/2006

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: 208G00000X , with the licence number:  2001001485 , 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: 1669584603 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00772953 . This is a "RR MCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 454668 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 205382807 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 604417 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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