1154562791 NPI number — THOMAS H ETTER D.O.

Table of content: THOMAS H ETTER D.O. (NPI 1154562791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154562791 NPI number — THOMAS H ETTER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETTER
Provider First Name:
THOMAS
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ETTER LLC
Provider Other First Name:
THOMAS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1154562791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 BLACKBURN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CODY
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82414-8494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-296-1355
Provider Business Mailing Address Fax Number:
307-586-5464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 BLACKBURN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-8494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-296-1355
Provider Business Practice Location Address Fax Number:
307-586-5464
Provider Enumeration Date:
03/11/2009

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: 208600000X , with the licence number:  TL2094 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 2006003130 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 9334A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 28058 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 921792 . This is a "HEALTHLINK INC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1154562791 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 622086 . This is a "ANTHEM BLUECROSS BLUESHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 9847314 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 12740475 . This is a "PHCS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 12740475 . This is a "MULTIPLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3032610 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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