1538324470 NPI number — PIA ERIKA HABERSANG

Table of content: PIA ERIKA HABERSANG (NPI 1538324470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538324470 NPI number — PIA ERIKA HABERSANG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABERSANG
Provider First Name:
PIA
Provider Middle Name:
ERIKA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1538324470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 WALLACE BLVD
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DEPT.
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79106-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-468-4300
Provider Business Mailing Address Fax Number:
806-468-4398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 MEDI PARK DR
Provider Second Line Business Practice Location Address:
STE 2051
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-468-4300
Provider Business Practice Location Address Fax Number:
806-468-4398
Provider Enumeration Date:
07/21/2008

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: 363L00000X , with the licence number:  445651 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0200X , with the licence number: 445651 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 042484804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53936353 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042484805 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200310180 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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