1023019015 NPI number — DR. NEFRETITI MER-EN-RA GARRISON-NORTH MD

Table of content: DR. NEFRETITI MER-EN-RA GARRISON-NORTH MD (NPI 1023019015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023019015 NPI number — DR. NEFRETITI MER-EN-RA GARRISON-NORTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARRISON-NORTH
Provider First Name:
NEFRETITI
Provider Middle Name:
MER-EN-RA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARRISON
Provider Other First Name:
NEFRETITI
Provider Other Middle Name:
MER-EN-RA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023019015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-331-5583
Provider Business Mailing Address Fax Number:
573-331-5079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 SAINT FRANCIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-5049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-331-5770
Provider Business Practice Location Address Fax Number:
573-331-3974
Provider Enumeration Date:
08/02/2005

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: 208000000X , with the licence number:  2011012785 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2011012785 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1042943 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023019015 . This is a "TRIWEST" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00314514 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".