1447210638 NPI number — MR. MARIO BAUTISTA SY M.D.

Table of content: ERICA MAIER (NPI 1427309483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447210638 NPI number — MR. MARIO BAUTISTA SY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SY
Provider First Name:
MARIO
Provider Middle Name:
BAUTISTA
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1447210638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 KIMBERLY RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-4193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-355-7733
Provider Business Mailing Address Fax Number:
563-355-9077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1351 KIMBERLY RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-4193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-355-7733
Provider Business Practice Location Address Fax Number:
563-355-9077
Provider Enumeration Date:
03/23/2006

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: 174400000X , with the licence number:  34978 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 34978 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2110700 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 421423259 . This is a "FEDERAL TAX INDENTIFICATI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34565 . This is a "WELLMARK BC BS" identifier . This identifiers is of the category "OTHER".




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