1366425084 NPI number — TROY M BURY DC

Table of content: TROY M BURY DC (NPI 1366425084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366425084 NPI number — TROY M BURY DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURY
Provider First Name:
TROY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1366425084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4030 BOARDMAN-CANFIELD RD
Provider Second Line Business Mailing Address:
STE 100C
Provider Business Mailing Address City Name:
CANFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-702-5555
Provider Business Mailing Address Fax Number:
330-702-0363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4030 BOARDMAN-CANFIELD RD
Provider Second Line Business Practice Location Address:
STE 100C
Provider Business Practice Location Address City Name:
CANFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-702-5555
Provider Business Practice Location Address Fax Number:
330-702-0363
Provider Enumeration Date:
11/28/2005

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: 111N00000X , with the licence number:  2759 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2292933 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7172056 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4497335 . This is a "UNITEDHEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 341906188026 . This is a "CARESOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000141917 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com