1649264276 NPI number — DR. NICHOLAS MARK MESSAMER MD

Table of content: DEJA L FARLEY (NPI 1871064477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649264276 NPI number — DR. NICHOLAS MARK MESSAMER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESSAMER
Provider First Name:
NICHOLAS
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHRISTENSEN MESSAMER
Provider Other First Name:
NICHOLAS
Provider Other Middle Name:
MARK
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649264276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 N 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSKALOOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52577-2495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-672-3360
Provider Business Mailing Address Fax Number:
641-672-3366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSKALOOSA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52577-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-672-3360
Provider Business Practice Location Address Fax Number:
641-672-3366
Provider Enumeration Date:
09/09/2005

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: 207Q00000X , with the licence number:  27198 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: IA0101 . This is a "JOHN DEERE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 7815 . This is a "MIDLAND CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080123337 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16D0950498 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5008800001 . This is a "CMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 46158 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 7050880 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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