1700957578 NPI number — GERARD GILBERT DESJARDINS CRNA

Table of content: GERARD GILBERT DESJARDINS CRNA (NPI 1700957578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700957578 NPI number — GERARD GILBERT DESJARDINS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESJARDINS
Provider First Name:
GERARD
Provider Middle Name:
GILBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1700957578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 664
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-622-4784
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 E 17TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-627-7000
Provider Business Practice Location Address Fax Number:
575-627-7007
Provider Enumeration Date:
11/13/2006

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: 367500000X , with the licence number:  R13732 , 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: 30264 . This is a "LOVELACE HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 430055194 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 14331 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM016018 . This is a "BLUE CROSS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 91215 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50655 . This is a "PRESBYTERIAN SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 11148 . This is a "LOVELACE SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 188124400 . This is a "DEPT OF LABOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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