1275645541 NPI number — VICKI L SKARDA D.O.

Table of content: VICKI L SKARDA D.O. (NPI 1275645541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275645541 NPI number — VICKI L SKARDA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKARDA
Provider First Name:
VICKI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUBESH
Provider Other First Name:
VICKI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275645541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 S ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CROIX FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54024-9449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-483-3221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 S ADAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CROIX FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54024-9449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-483-3221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

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: 207Q00000X , with the licence number:  43271 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 072J3KU . This is a "BLUE CROSS MN FACILITY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 080176515 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 072J4KU . This is a "BLUE CROSS MN PRO FEE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0107134 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 43494800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP33862 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: NA9031028480 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 444251200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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