1558331439 NPI number — MS. PHYLLIS R GREEN WHCNP

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558331439 NPI number — MS. PHYLLIS R GREEN WHCNP

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GREEN

Provider First Name:

PHYLLIS

Provider Middle Name:

R

Provider Name Prefix Text:

MS.

Provider Name Suffix Text:

Provider Credential Text:

WHCNP

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

BERG

Provider Other First Name:

PHYLLIS

Provider Other Middle Name:

R

Provider Other Name Prefix Text:

MRS.

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

1

NPI Number:

1558331439

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/10/2010

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3425 1ST AVE SE

Provider Second Line Business Mailing Address:

SUITE 100

Provider Business Mailing Address City Name:

CEDAR RAPIDS

Provider Business Mailing Address State Name:

IA

Provider Business Mailing Address Postal Code:

52402-6155

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

319-363-3459

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

3425 1ST AVE SE

Provider Second Line Business Practice Location Address:

SUITE 100

Provider Business Practice Location Address City Name:

CEDAR RAPIDS

Provider Business Practice Location Address State Name:

IA

Provider Business Practice Location Address Postal Code:

52402-6155

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

319-363-3459

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

01/24/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LW0102X , with the licence number:  F-076357 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 07-12543 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
• Identifier: 1043738 . This is a "AMERICA'S PPO (ARAZ)" identifier . This identifiers is of the category "OTHER".
• Identifier: 095817400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 6826080 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 6826082 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: HP39675 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 23511 . This is a "SIOUX VALLEY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 122187 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 32B01BE . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 4998913 . This is a "BCBS SD (WELLMARK)" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 10025013500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1017855 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
• Identifier: 4998568 . This is a "BCBS SD (WELLMARK)" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".