1861534950 NPI number — STEVEN R PATTY DDS PA

Table of content: (NPI 1861534950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861534950 NPI number — STEVEN R PATTY DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN R PATTY DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1861534950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1851 WELLNESS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28110-7774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-291-7333
Provider Business Mailing Address Fax Number:
704-292-1203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1851 WELLNESS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110-7774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-291-7333
Provider Business Practice Location Address Fax Number:
704-292-1203
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATTY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-291-7333

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  5322 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 328400 . This is a "TRIGON BCBS INS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 8996674 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 583212 . This is a "UNITED CONCORDIA INS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 96674 . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: ZN5322 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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