1780865626 NPI number — BETSY M VAN GENDEREN CNP

Table of content: BETSY M VAN GENDEREN CNP (NPI 1780865626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780865626 NPI number — BETSY M VAN GENDEREN CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GENDEREN
Provider First Name:
BETSY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEISMANTEL
Provider Other First Name:
BETSY
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780865626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-6585
Provider Business Mailing Address Fax Number:
605-328-6512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 HIGHLAND WAY STE K
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MITCHELL
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57301-6409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-996-0440
Provider Business Practice Location Address Fax Number:
605-996-0401
Provider Enumeration Date:
11/20/2007

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: 363LF0000X , with the licence number:  CP000508 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4992440 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 254961 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1134191869 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C70501053906 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1780865626 . This is a "ARAZ/AMERICA'S PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9255156 . This is a "DAKOTACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 75L18VA . This is a "CC SYSTEMS/BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57105N005 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6829990 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 854618200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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