1104800655 NPI number — DR. GREGORY STUART SYVERTSON PT, DPT, CFT,CCI

Table of content: DR. GREGORY STUART SYVERTSON PT, DPT, CFT,CCI (NPI 1104800655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104800655 NPI number — DR. GREGORY STUART SYVERTSON PT, DPT, CFT,CCI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYVERTSON
Provider First Name:
GREGORY
Provider Middle Name:
STUART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CFT,CCI
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SYVERTSON
Provider Other First Name:
GREG
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, CFT,CCI
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104800655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 767
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANIELS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25832-0767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-252-4170
Provider Business Mailing Address Fax Number:
304-252-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 JOHN RAINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAINELLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25962-1457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-438-9225
Provider Business Practice Location Address Fax Number:
304-438-9226
Provider Enumeration Date:
11/29/2005

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: 225100000X , with the licence number:  0001489 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5534228 . This is a "FIRST HEALTH" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 612406500 . This is a "DOL FECA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 697891 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 9420008-000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1064530 . This is a "BRICKSTREET WC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7239017 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001714553 . This is a "MSBCBS INDIVIDUAL PIN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 87316 . This is a "UNICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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