1720062458 NPI number — JANA G VAN WIE MD

Table of content: JANA G VAN WIE MD (NPI 1720062458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720062458 NPI number — JANA G VAN WIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN WIE
Provider First Name:
JANA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1720062458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3016 W FAIDLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-382-8546
Provider Business Mailing Address Fax Number:
308-381-8546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3016 W FAIDLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-381-8546
Provider Business Practice Location Address Fax Number:
308-381-8550
Provider Enumeration Date:
12/06/2005

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:  16706 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 2801-16706 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00885788 . This is a "RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1720062458 . This is a "NPI" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 45359 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 6501500001 . This is a "MEDICARE DME PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 097552 . This is a "GROUP PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 097552008 . This is a "PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1669781225 . This is a "GROUP NPI" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 248833 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1033117015 . This is a "GROUP NPI" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025894200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com