1093784399 NPI number — CITY OF BRIDGEPORT

Table of content: (NPI 1093784399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093784399 NPI number — CITY OF BRIDGEPORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF BRIDGEPORT
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:
6
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:
1093784399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
422 S BELTLINE HWY E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSBLUFF
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69361-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-635-0511
Provider Business Mailing Address Fax Number:
308-635-0164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69336-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-635-0511
Provider Business Practice Location Address Fax Number:
308-635-0164
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAUMGARTNER
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BILLING CLERK
Authorized Official Telephone Number:
308-635-0511

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  1039 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025261100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39409 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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