1932190790 NPI number — MICHELE L PEITZ PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932190790 NPI number — MICHELE L PEITZ PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEITZ
Provider First Name:
MICHELE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1932190790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 N FOSTER ST
Provider Second Line Business Mailing Address:
STE 108
Provider Business Mailing Address City Name:
MITCHELL
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57301-2971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-928-3311
Provider Business Mailing Address Fax Number:
605-928-4417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 W GLYNN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKSTON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57366-9605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-928-3311
Provider Business Practice Location Address Fax Number:
605-928-4417
Provider Enumeration Date:
11/02/2005

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: 363A00000X , with the licence number:  0367 , 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: 9238106 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5340340 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6825764 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4994846 . This is a "WELLMARK TRIPP" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5340070 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4994847 . This is a "WELLMARK LAKE ANDES" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6825765 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4994845 . This is a "WELLMARK PARKSTON" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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