1699968875 NPI number — MICHAEL B DEBRULE DPM, PA

Table of content: LOURIZZA MAE CATAGUE SAMPALOCIA (NPI 1114102795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699968875 NPI number — MICHAEL B DEBRULE DPM, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL B DEBRULE DPM, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1699968875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 OCONNELL ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56258-3773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-532-4676
Provider Business Mailing Address Fax Number:
507-929-1041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHALL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56258-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-532-4676
Provider Business Practice Location Address Fax Number:
507-929-1041
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEBRULE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-532-4676

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 439392900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59G28DE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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