1003012238 NPI number — RODNEY PAUL WALKER CERTIFIED 15 YEARS

Table of content: RODNEY PAUL WALKER CERTIFIED 15 YEARS (NPI 1003012238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003012238 NPI number — RODNEY PAUL WALKER CERTIFIED 15 YEARS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
RODNEY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED 15 YEARS
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:
1003012238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 295
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST UNION
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45693-0295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-544-7200
Provider Business Mailing Address Fax Number:
937-544-7211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1216 LOGANS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST UNION
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45693-9631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-544-7200
Provider Business Practice Location Address Fax Number:
937-544-7211
Provider Enumeration Date:
06/25/2007

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: 171WH0202X , with the licence number:  NONE REQUIRED , 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: 0240724 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2644606 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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