1932316940 NPI number — MR. MICHAEL T HIMMELMAN PT

Table of content: MR. MICHAEL T HIMMELMAN PT (NPI 1932316940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932316940 NPI number — MR. MICHAEL T HIMMELMAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIMMELMAN
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1932316940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2725 N WESTWOOD BLVD
Provider Second Line Business Mailing Address:
SUITE 17
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-2346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-686-4277
Provider Business Mailing Address Fax Number:
573-686-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 PHYSICIANS PARK
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-9348
Provider Business Practice Location Address Fax Number:
573-686-4870
Provider Enumeration Date:
05/17/2007

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: 225100000X , with the licence number:  PT2966 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: PT2966 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: PT2966 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2011037087 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , with the licence number: 2011037087 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: 2011037087 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 164036721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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