1346222940 NPI number — ROBERT D FULLINWIDER JR. CRNA

Table of content: ROBERT D FULLINWIDER JR. CRNA (NPI 1346222940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346222940 NPI number — ROBERT D FULLINWIDER JR. CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLINWIDER
Provider First Name:
ROBERT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
CRNA
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:
1346222940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3705 MEDICAL PKWY
Provider Second Line Business Mailing Address:
SUITE 570
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78705-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-454-2454
Provider Business Mailing Address Fax Number:
512-454-1532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3705 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 570
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78705-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-454-2454
Provider Business Practice Location Address Fax Number:
512-454-1532
Provider Enumeration Date:
11/18/2005

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: 367500000X , with the licence number:  29196 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 80212C . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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