1740385236 NPI number — MARY E. OLIVA P.A.-C,

Table of content: MARY E. OLIVA P.A.-C, (NPI 1740385236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740385236 NPI number — MARY E. OLIVA P.A.-C,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIVA
Provider First Name:
MARY
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C,
Provider Gender Code:
F

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:
1740385236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-258-4401
Provider Business Mailing Address Fax Number:
859-258-4418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-258-4401
Provider Business Practice Location Address Fax Number:
859-258-4418
Provider Enumeration Date:
09/13/2006

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: 363A00000X , with the licence number:  PA636 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA636 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 95001541 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37903705 . This is a "MEDICAID LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4000501 . This is a "MEDICARE LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CB5773 . This is a "RR MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".




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