1013056456 NPI number — DR. BEAU ANTHONY GREGERSEN D.C

Table of content: DR. BEAU ANTHONY GREGERSEN D.C (NPI 1013056456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013056456 NPI number — DR. BEAU ANTHONY GREGERSEN D.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGERSEN
Provider First Name:
BEAU
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C
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:
1013056456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 W 58TH ST
Provider Second Line Business Mailing Address:
SUITE# 407
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10019-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-765-6470
Provider Business Mailing Address Fax Number:
212-333-7346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 W 58TH ST
Provider Second Line Business Practice Location Address:
SUITE# 407
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10019-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-765-6470
Provider Business Practice Location Address Fax Number:
212-333-7346
Provider Enumeration Date:
02/05/2007

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: 111N00000X , with the licence number:  X011304-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 10129 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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