1851394738 NPI number — PHILIP B SEXTRO DPM

Table of content: PHILIP B SEXTRO DPM (NPI 1851394738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851394738 NPI number — PHILIP B SEXTRO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEXTRO
Provider First Name:
PHILIP
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1851394738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 DIERS AVE
Provider Second Line Business Mailing Address:
PO BOX 5020
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68802-5020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-381-0404
Provider Business Mailing Address Fax Number:
308-381-0408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 DIERS 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:
68802-5020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-381-0404
Provider Business Practice Location Address Fax Number:
308-381-0408
Provider Enumeration Date:
05/24/2005

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: 213ES0103X , with the licence number:  213E00000X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 135 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 470624949 . This is a "CHAMPUS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 280175 . This is a "MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 0152470001 . This is a "DMERC CIGNA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 0152470001 . This is a "CIGNA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 02549 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47062497913 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480021804 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".