1164590204 NPI number — PICKERT MEDICAL GROUP, P.C.

Table of content: (NPI 1164590204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164590204 NPI number — PICKERT MEDICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PICKERT MEDICAL GROUP, P.C.
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:
CLASS, IDLER AND ASSOCIATES, P.C.
Provider Other Organization Name Type Code:
4
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:
1164590204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 WALT WHITMAN RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-208-4250
Provider Business Mailing Address Fax Number:
704-248-5537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 E LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 555
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89501-2097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-348-1900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOBERG
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
774-750-4110

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100505684 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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