1619922531 NPI number — MARJORIE K TRIEBOLD PAC

Table of content: MARJORIE K TRIEBOLD PAC (NPI 1619922531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619922531 NPI number — MARJORIE K TRIEBOLD PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRIEBOLD
Provider First Name:
MARJORIE
Provider Middle Name:
K
Provider Name Prefix Text:
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:
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:
1619922531
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58108-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-253-5300
Provider Business Mailing Address Fax Number:
701-253-5402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 3RD ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58401-4247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-253-5300
Provider Business Practice Location Address Fax Number:
701-253-5402
Provider Enumeration Date:
05/23/2006

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: 363AM0700X , with the licence number:  PAC0188 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31Q26TR . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 540698600 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA9061015526 . This is a "PREFERRED ONE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 142353 . This is a "UCARE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: HP38589 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 0111506 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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