1689785974 NPI number — JOPPA MAGNOLIA VOLUNTEER FIRE CO. INC.

Table of content: (NPI 1689785974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689785974 NPI number — JOPPA MAGNOLIA VOLUNTEER FIRE CO. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOPPA MAGNOLIA VOLUNTEER FIRE CO. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689785974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1403 OLD MOUNTAIN ROAD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPPA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21085-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-679-1055
Provider Business Mailing Address Fax Number:
410-679-3420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1403 OLD MOUNTAIN ROAD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPPA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21085-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-679-1055
Provider Business Practice Location Address Fax Number:
410-679-3420
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-679-1055

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 590008873 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: Y938 . This is a "CAREFIRST BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 914550800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: T413 . This is a "FEDERAL BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".