1114004462 NPI number — RICHARD STOVALL MD PA

Table of content: (NPI 1114004462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114004462 NPI number — RICHARD STOVALL MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD STOVALL MD PA
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:
NEUROSURGICAL ASSOCIATES OF AUSTIN
Provider Other Organization Name Type Code:
3
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:
1114004462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25887
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73125-0887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-835-8100
Provider Business Mailing Address Fax Number:
512-835-8101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 PARK BEND DR
Provider Second Line Business Practice Location Address:
BLDG 2, STE 201
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78758-5388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-835-8100
Provider Business Practice Location Address Fax Number:
512-835-8101
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ONTIVEROS
Authorized Official First Name:
MANDY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
512-835-8100

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  K5409 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0098MS . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 175502701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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