1225023070 NPI number — ADAGIO DERMATOLOGY AND AESTHETICS, P.A.

Table of content: (NPI 1225023070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225023070 NPI number — ADAGIO DERMATOLOGY AND AESTHETICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADAGIO DERMATOLOGY AND AESTHETICS, P.A.
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:
LAURA J. HAYGOOD, M.D., P.A.
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:
1225023070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 RICE ROAD
Provider Second Line Business Mailing Address:
STE. 104
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-3604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-597-3376
Provider Business Mailing Address Fax Number:
903-526-7703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 RICE ROAD
Provider Second Line Business Practice Location Address:
STE. 104
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-597-3376
Provider Business Practice Location Address Fax Number:
903-526-7703
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAYGOOD
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
JENNIFER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-597-3376

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  K3905 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0082DN . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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