1316963366 NPI number — DONALD L BADER

Table of content: DONALD L BADER (NPI 1316963366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316963366 NPI number — DONALD L BADER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BADER
Provider First Name:
DONALD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BADER
Provider Other First Name:
DONALD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1316963366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 589
Provider Second Line Business Mailing Address:
FT DEFIANCE INDIAN HOSPITAL BOARD
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504-0589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-729-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CORNER OF ROUTE N12 AND N7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504-0589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-729-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

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: 207P00000X , with the licence number:  36859 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 930060672 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00448188 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 000S2505 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01368596 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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