1235187642 NPI number — VERICARE, P.C.

Table of content: (NPI 1235187642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235187642 NPI number — VERICARE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERICARE, 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:
VERICARE
Provider Other Organization Name Type Code:
3
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:
1235187642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/11/2007
NPI Reactivation Date:
08/08/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 HATCHETTS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD LYME
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06371-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-370-3651
Provider Business Mailing Address Fax Number:
877-515-7147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 JACKSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731-6060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-257-8715
Provider Business Practice Location Address Fax Number:
800-819-1655
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CREDENTIALING ENROLLMENT
Authorized Official Telephone Number:
800-370-3651

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CB3582 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 136136210 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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