1871509224 NPI number — JUDY JICINSKY P.T.

Table of content: JUDY JICINSKY P.T. (NPI 1871509224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871509224 NPI number — JUDY JICINSKY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JICINSKY
Provider First Name:
JUDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1871509224
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:
1585 EAGLE VIEW CT NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWISHER
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52338-9437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-981-2276
Provider Business Mailing Address Fax Number:
319-363-2903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 32ND AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52404-3947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-363-2901
Provider Business Practice Location Address Fax Number:
319-363-2903
Provider Enumeration Date:
07/31/2006

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: 208100000X , with the licence number:  02851 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0429027 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30406 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F232553 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P00062328 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".