1003922030 NPI number — DR. ROY WILLIAM BACKUS O.D.

Table of content: DR. CALVIN LIMBERG PHARM.D. (NPI 1740174135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003922030 NPI number — DR. ROY WILLIAM BACKUS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKUS
Provider First Name:
ROY
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1003922030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38050 JEFFERY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BRANCH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55056-5908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-237-0330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 12TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55025-1482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-464-9767
Provider Business Practice Location Address Fax Number:
651-464-9062
Provider Enumeration Date:
08/22/2006

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: 152W00000X , with the licence number:  2520 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22-14902 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 48705 . This is a "DAVIS VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4100006627 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6C258BA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 152144 . This is a "COLE VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410042867 . This is a "RAILROAD PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 212298 . This is a "BCBS OPTI CHOICE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12060 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 489437500 . This is a "MN HEALTH CARE PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 71-0415188 . This is a "SUPERIOR VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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