1689852196 NPI number — THEODORE B GELLERT PA-C

Table of content: THEODORE B GELLERT PA-C (NPI 1689852196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689852196 NPI number — THEODORE B GELLERT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GELLERT
Provider First Name:
THEODORE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GELLERT
Provider Other First Name:
TED
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1689852196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 SALAMANCA ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS RANCHOS DE ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87107-5620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-345-0330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 LOMAS BLVD NE
Provider Second Line Business Practice Location Address:
MSC10-5610 2-ACC
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-6901
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2008

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: 363AS0400X , with the licence number:  PA2007-0036 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 995993 . This is a "UNMH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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