1528020229 NPI number — JEN MED PROF LLC

Table of content: (NPI 1528020229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528020229 NPI number — JEN MED PROF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEN MED PROF LLC
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:
STURGIS MEDICAL CENTER
Provider Other Organization Name Type Code:
4
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:
1528020229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 BALLPARK RD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
STURGIS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57785-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-347-3684
Provider Business Mailing Address Fax Number:
605-347-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 BALLPARK RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
STURGIS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57785-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-347-3684
Provider Business Practice Location Address Fax Number:
605-347-0083
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JENTER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
605-347-3684

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1034 , 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: 142389900 . This is a "OWCP PROVIDER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 42339 . This is a "RADIATION MEDICAL LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 14172-1 . This is a "FAA LICENSE NUMBER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5602360 . This is a "TITLE 19" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: S2312 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1034 . This is a "PHYSICIAN'S LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 43D0408177 . This is a "CLIA LAB" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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