1023087012 NPI number — DR. GLADSTONE A TUCKER MD

Table of content: DR. GLADSTONE A TUCKER MD (NPI 1023087012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023087012 NPI number — DR. GLADSTONE A TUCKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
GLADSTONE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023087012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 752
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORDIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64020-0752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-463-1365
Provider Business Mailing Address Fax Number:
660-463-1367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1606 CASTLEBERRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-1586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-9519
Provider Business Practice Location Address Fax Number:
618-993-0592
Provider Enumeration Date:
03/14/2006

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: 208M00000X , with the licence number:  036111926 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 036111926 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 252364 . This is a "HARMONY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036111926 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07332006 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 229260 . This is a "COVENTRY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00239844 . This is a "MEDICARE - RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 699628 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 9367182 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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