1598738635 NPI number — MRS. TRINA GEBAUER BLAIR PAC

Table of content: MRS. TRINA GEBAUER BLAIR PAC (NPI 1598738635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598738635 NPI number — MRS. TRINA GEBAUER BLAIR PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAIR
Provider First Name:
TRINA
Provider Middle Name:
GEBAUER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEBAUER
Provider Other First Name:
TRINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598738635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3415 53RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-6976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-742-4350
Provider Business Mailing Address Fax Number:
563-742-4355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3415 53RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-6976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-742-4350
Provider Business Practice Location Address Fax Number:
563-742-4355
Provider Enumeration Date:
02/09/2006

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: 363A00000X , with the licence number:  085002304 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 001563 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1598738635 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00277546 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116106 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37592 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com