1376512137 NPI number — DR. MARK D. WADE O.D.

Table of content: HANNAH ANDERSON (NPI 1881445187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376512137 NPI number — DR. MARK D. WADE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADE
Provider First Name:
MARK
Provider Middle Name:
D.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1376512137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 E BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-336-4690
Provider Business Mailing Address Fax Number:
800-432-6004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12601 OLIVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-6313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-336-4690
Provider Business Practice Location Address Fax Number:
800-432-6004
Provider Enumeration Date:
03/15/2006

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: 152W00000X , with the licence number:  T02999 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 046-008455 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 313117905 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4210 . This is a "MISSOURI MEDICAID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 108459 . This is a "BLUE CROSS BLUE SHIELD MO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 313117913 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22-01100 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 237550 . This is a "HELATHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 046008455 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 222865 . This is a "GROUP HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116865 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12139 . This is a "OPTICARE MEDICARE COMPLET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 410048083 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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