1740235266 NPI number — ANDREW BASLER DAHLGREN MD

Table of content: ANDREW BASLER DAHLGREN MD (NPI 1740235266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740235266 NPI number — ANDREW BASLER DAHLGREN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLGREN
Provider First Name:
ANDREW
Provider Middle Name:
BASLER
Provider Name Prefix Text:
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:
1740235266
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 BOULDERS PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
NORTH CHESTERFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23225-4067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-560-5595
Provider Business Mailing Address Fax Number:
804-560-9029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8200 MEADOWBRIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23116-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-730-2121
Provider Business Practice Location Address Fax Number:
804-730-0563
Provider Enumeration Date:
05/23/2006

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: 207RS0010X , with the licence number:  4301074317 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: 0101057080 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 0101057080 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 104800110 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00761603 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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