1760631832 NPI number — MULTI-SPECIALTY DIAGNOSTIC CENTER REBECCA A PREISS GEN PTR

Table of content: (NPI 1760631832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760631832 NPI number — MULTI-SPECIALTY DIAGNOSTIC CENTER REBECCA A PREISS GEN PTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MULTI-SPECIALTY DIAGNOSTIC CENTER REBECCA A PREISS GEN PTR
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:
MULTI-SPECIALTY DIAGNOSTIC CENTER
Provider Other Organization Name Type Code:
3
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:
1760631832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6511 US HIGHWAY 181 N
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FLORESVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78114-6281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-815-1202
Provider Business Mailing Address Fax Number:
830-815-1205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6511 US HIGHWAY 181 N
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FLORESVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78114-6281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-815-1202
Provider Business Practice Location Address Fax Number:
830-815-1205
Provider Enumeration Date:
09/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KIZZART
Authorized Official First Name:
JEROME
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
830-815-1202

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  H3823 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: H3823 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0200X , with the licence number: M6603 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: M6603 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: M6603 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0011X , with the licence number: H3823 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: H3823 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 95RT . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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