1043218084 NPI number — JOHN VAN EARNHART M.D.

Table of content: (NPI 1306966015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043218084 NPI number — JOHN VAN EARNHART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARNHART
Provider First Name:
JOHN
Provider Middle Name:
VAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1043218084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/31/2006
NPI Reactivation Date:
05/01/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 S MOUNT AUBURN RD
Provider Second Line Business Mailing Address:
SUITE 418
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63703-4911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-332-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S MOUNT AUBURN RD
Provider Second Line Business Practice Location Address:
SUITE 418
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-332-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2005

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: 207Q00000X , with the licence number:  036-106126 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2013002771 , 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: H67921 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 076839 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: H67921 . This is a "CHAMPVA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: H67921 . This is a "TRICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036-106126 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036106126 . This is a "IDPA FEE FOR SERVICE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: H67921 . This is a "UNITED HEALTHCARE RR MEDI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1043218084 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 473444 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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