1396704763 NPI number — SUSAN J ADRIAN NP

Table of content: SUSAN J ADRIAN NP (NPI 1396704763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396704763 NPI number — SUSAN J ADRIAN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADRIAN
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1396704763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 67250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506-7250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-328-8833
Provider Business Mailing Address Fax Number:
402-328-2921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43140-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-845-7600
Provider Business Practice Location Address Fax Number:
740-845-7676
Provider Enumeration Date:
03/22/2006

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: 163W00000X , with the licence number:  RN150849 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: NP00603 , 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: 141867207028 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2119764 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000286657 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00354251 . This is a "RRM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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