1457363194 NPI number — DONALD J ROESLER CRNA

Table of content: DONALD J ROESLER CRNA (NPI 1457363194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457363194 NPI number — DONALD J ROESLER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROESLER
Provider First Name:
DONALD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1457363194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 S CLIFF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-1007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-2754
Provider Business Mailing Address Fax Number:
605-322-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 S CLIFF AVE
Provider Second Line Business Practice Location Address:
ATTN: P.F.S.
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-6428
Provider Business Practice Location Address Fax Number:
605-322-6499
Provider Enumeration Date:
08/12/2006

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: 367500000X , with the licence number:  R025309-0320 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0002363 . This is a "SD BLUE CROSS PROV #" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 460224743-48 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143458600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: R025309 . This is a "DAKOTACARE PROV #" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 2121590 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5751096 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 013K6RO . This is a "MN BLUE CROSS PROV#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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