1982656724 NPI number — DR. MARY BRODERICK CHRISTENSEN MD

Table of content: DR. MARY BRODERICK CHRISTENSEN MD (NPI 1982656724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982656724 NPI number — DR. MARY BRODERICK CHRISTENSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTENSEN
Provider First Name:
MARY
Provider Middle Name:
BRODERICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRODERICK
Provider Other First Name:
MARY
Provider Other Middle Name:
ANGELA PEARL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982656724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 9TH ST
Provider Second Line Business Mailing Address:
ROOM 205 MAILSTOP 23
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95814-6414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-654-2431
Provider Business Mailing Address Fax Number:
916-654-2431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15000 ARNOLD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELDRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95431-8900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-938-6690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2006

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: 207Q00000X , with the licence number:  G72502 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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