1144557208 NPI number — NAVAL HEALTH CLINIC GREAT LAKES

Table of content: DR. BRAM IZUTSU HOLLADAY DMD (NPI 1881449239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144557208 NPI number — NAVAL HEALTH CLINIC GREAT LAKES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAVAL HEALTH CLINIC GREAT LAKES
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:
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:
1144557208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3350 ILLINOIS STREET BLDG 1523
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
60088-5230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
846-688-5568
Provider Business Mailing Address Fax Number:
847-688-2289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3350 ILLINOIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-688-5568
Provider Business Practice Location Address Fax Number:
847-688-2289
Provider Enumeration Date:
11/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GEIBE
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL OFFICER
Authorized Official Telephone Number:
847-688-6712

Provider Taxonomy Codes

  • Taxonomy code: 261QM1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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