1902833627 NPI number — DAVID A DAGEFORDE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902833627 NPI number — DAVID A DAGEFORDE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAGEFORDE
Provider First Name:
DAVID
Provider Middle Name:
A
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:
FINE
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CREDNTLG COORDINATOR
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1902833627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-272-5395
Provider Business Mailing Address Fax Number:
502-272-5339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 DUTCHMANS LN STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-896-2120
Provider Business Practice Location Address Fax Number:
502-896-2110
Provider Enumeration Date:
06/27/2006

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: 207RC0000X , with the licence number:  20071 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50031154 . This is a "PASSPORT & PASSPORT ADVTG - NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00889587 . This is a "MEDICARE RR - NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1056110 . This is a "PASSPORT PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000693027 . This is a "ANTHEM - NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64200710 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100388760F , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060018530 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000044911 . This is a "ANTHEM PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000057080C . This is a "HUMANA - NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0203578000 . This is a "PASSPORT ADVANAGE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100388760A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com