1174510879 NPI number — MR. CHAD P ENICH PA C

Table of content: MR. CHAD P ENICH PA C (NPI 1174510879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174510879 NPI number — MR. CHAD P ENICH PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENICH
Provider First Name:
CHAD
Provider Middle Name:
P
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA C
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:
1174510879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 86TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50322-4201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-276-3406
Provider Business Mailing Address Fax Number:
515-276-5141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 86TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
URBANDALE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50322-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-276-3406
Provider Business Practice Location Address Fax Number:
515-276-5141
Provider Enumeration Date:
09/29/2005

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:  01165 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 146N00000X , with the licence number: 001165 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2133348 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44593 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1174510879 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 970009403 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P01396066 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".