1205013455 NPI number — MICHAEL D. ADAMS, M.D., P.C.

Table of content: (NPI 1205013455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205013455 NPI number — MICHAEL D. ADAMS, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL D. ADAMS, M.D., 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:
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:
1205013455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 YELLOW CREEK RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82930-5235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-789-8290
Provider Business Mailing Address Fax Number:
307-789-8290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 YELLOW CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82930-5235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-789-8290
Provider Business Practice Location Address Fax Number:
307-789-8290
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OLDHAM
Authorized Official First Name:
NIKKI
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS SUPERVISOR
Authorized Official Telephone Number:
435-755-6061

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4371-A , 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: 0004116106 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02902001 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 080014492 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: C12604 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103977600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53D0977203 . This is a "CLIA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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