1215044540 NPI number — BILL P EVANS DO

Table of content: BILL P EVANS DO (NPI 1215044540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215044540 NPI number — BILL P EVANS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
BILL
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1215044540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87499-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-609-2258
Provider Business Mailing Address Fax Number:
505-609-2259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3637 4TH ST N
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33704-1355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-823-2188
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2006

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: 207L00000X , with the licence number:  OS5752 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 057120200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 050023153 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 80504 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 057120200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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