1336144559 NPI number — MRS. MARIJANE RABOIN BEELAND APRN

Table of content: KAREN YVETTE GONZALEZ (NPI 1013609411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336144559 NPI number — MRS. MARIJANE RABOIN BEELAND APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEELAND
Provider First Name:
MARIJANE
Provider Middle Name:
RABOIN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOHLLEB
Provider Other First Name:
MARIJANE
Provider Other Middle Name:
SARAH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336144559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 DUTCHMANS LN STE 503
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-409-5600
Provider Business Practice Location Address Fax Number:
502-409-5606
Provider Enumeration Date:
06/15/2005

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: 174400000X , with the licence number:  7100790 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X , with the licence number: 3004812 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200489110 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01300054 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: K099480 . This is a "MEDICARE PTAN - WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000215953 . This is a "BC/BS FACETS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100272410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500029280 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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