1467542399 NPI number — BLACK HILLS FAMILY PRACTICE CLINIC PS

Table of content: (NPI 1467542399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467542399 NPI number — BLACK HILLS FAMILY PRACTICE CLINIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK HILLS FAMILY PRACTICE CLINIC PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1467542399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCLEARY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98557-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-495-3475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
332 S BIRCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCLEARY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98557-9522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-495-3475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACKE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-495-3475

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 15628 . This is a "SLI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008N . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 75243 . This is a "UNIFORM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1009515 . This is a "COMMUNITY H" identifier . This identifiers is of the category "OTHER".
  • Identifier: A002 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MA8267 . This is a "REGENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 95958 . This is a "PACIFIC CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: QMXPR0055448 . This is a "MOLINA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1252402 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8009961 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com