1306828009 NPI number — FREDERICK P JAECKLEIN MD

Table of content: FREDERICK P JAECKLEIN MD (NPI 1306828009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306828009 NPI number — FREDERICK P JAECKLEIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAECKLEIN
Provider First Name:
FREDERICK
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1306828009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
916-920-8775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 W. FAIR AVENUE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-4500
Provider Business Practice Location Address Fax Number:
906-225-3919
Provider Enumeration Date:
11/17/2005

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: 207RH0000X , with the licence number:  049842 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 049842 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110030846 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 381358036011 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3138366 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com