1831155357 NPI number — DR. MARK E STORTVEDT PH.D.

Table of content: DR. MARK E STORTVEDT PH.D. (NPI 1831155357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831155357 NPI number — DR. MARK E STORTVEDT PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STORTVEDT
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1831155357
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:
333 W NORFOLK AVE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68701-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-379-2030
Provider Business Mailing Address Fax Number:
402-379-3933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 W NORFOLK AVE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68701-5401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-379-2030
Provider Business Practice Location Address Fax Number:
402-379-3933
Provider Enumeration Date:
04/24/2006

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: 101YM0800X , with the licence number:  1769 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP2500X , with the licence number: 1243 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 84924 . This is a "BC/BS INDIVIDUAL" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 92015 . This is a "BC/BS SUPERVISOR" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 7893 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 39189435426 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".