1154326544 NPI number — RODNEY KENT VAN ANDEL M.D.

Table of content: MR. ARTHUR DAVANZO (NPI 1164716452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154326544 NPI number — RODNEY KENT VAN ANDEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN ANDEL
Provider First Name:
RODNEY
Provider Middle Name:
KENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1154326544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75712-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:
903-593-7569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3203 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75771-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-266-4000
Provider Business Practice Location Address Fax Number:
903-882-7751
Provider Enumeration Date:
06/14/2005

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: 207Q00000X , with the licence number:  L7909 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X , with the licence number: L7909 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 138771100 . This is a "FIRSTCARE SOUTHWEST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00165779 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 166412003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K1901 . This is a "TEXAS BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 001 . This is a "TRICARE CANTON LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 002 . This is a "TRICARE LAKE PALESTINE LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TIN PLUS 028 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PP10013213 . This is a "TEXAS WORKERS COMP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129375 . This is a "CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8V5495 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 166412001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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