1902807118 NPI number — BRADLEY VARGO DO

Table of content: BRADLEY VARGO DO (NPI 1902807118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902807118 NPI number — BRADLEY VARGO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARGO
Provider First Name:
BRADLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1902807118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11255 WOODLAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRTLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44094-9556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-832-9683
Provider Business Mailing Address Fax Number:
440-256-3147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11255 WOODLAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRTLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094-9556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-832-9683
Provider Business Practice Location Address Fax Number:
440-256-3147
Provider Enumeration Date:
08/10/2005

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: 207LC0200X , with the licence number:  34004864 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 34004864 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000221087 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 415050 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0583328 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 751022 . This is a "BUCKEYE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5693771 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000521139 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0825816 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com