1518915503 NPI number — DR. NANCY L BRUDA MD

Table of content: DR. NANCY L BRUDA MD (NPI 1518915503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518915503 NPI number — DR. NANCY L BRUDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUDA
Provider First Name:
NANCY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1518915503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72702-1867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-664-9892
Provider Business Mailing Address Fax Number:
918-664-2521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3215 N NORTHHILLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-4424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-664-9892
Provider Business Practice Location Address Fax Number:
918-664-2521
Provider Enumeration Date:
05/04/2006

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: 207L00000X , with the licence number:  118708 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: E-5371 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100317990B , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136770001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 771081401 . This is a "ARKANSAS BREASTCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 203843420 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00664032 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 200126940A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26178025 . This is a "BCBS NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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