1144216458 NPI number — BRETT D TEVELDAL PT

Table of content: BRETT D TEVELDAL PT (NPI 1144216458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144216458 NPI number — BRETT D TEVELDAL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEVELDAL
Provider First Name:
BRETT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1144216458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 S CLIFF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-2129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-334-5630
Provider Business Mailing Address Fax Number:
605-332-5327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 S CLIFF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-334-5630
Provider Business Practice Location Address Fax Number:
605-332-5327
Provider Enumeration Date:
09/22/2005

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:  1042 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5833143 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27416 . This is a "SIOUX VALLEY HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4994832 . This is a "BLUE CROSS BLUE SHIELD SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 64-03937 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 64-04055 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 361J8TE . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5833144 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64-03936 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1042.1 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1810856 . This is a "ARAZ" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4996126 . This is a "BLUE CROSS BLUE SHIELD SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 64-05333 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4996418 . This is a "BLUE CROSS BLUE SHIELD SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5833142 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5833140 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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