1699795872 NPI number — DR. JOHN D. TYLER

Table of content: DR. JOHN D. TYLER (NPI 1699795872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699795872 NPI number — DR. JOHN D. TYLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYLER
Provider First Name:
JOHN
Provider Middle Name:
D.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1699795872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 S COLUMBIA RD
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-5895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-772-1588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 S COLUMBIA RD
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-5895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-772-1588
Provider Business Practice Location Address Fax Number:
701-746-6077
Provider Enumeration Date:
07/20/2006

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: 103TC0700X , with the licence number:  37 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A006 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0005663645 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 974701009768 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: TYL5227 . This is a "ND BLUE CROSS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 2H520TY . This is a "MN BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 16979 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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