1043497258 NPI number — HARVEY G VAN DELL, MD, PA, PLLC

Table of content: (NPI 1043497258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043497258 NPI number — HARVEY G VAN DELL, MD, PA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARVEY G VAN DELL, MD, PA, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1043497258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2980 LONG PRAIRIE RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
FLOWER MOUND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75022-4845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-899-9787
Provider Business Mailing Address Fax Number:
972-899-9786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2980 LONG PRAIRIE RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75022-4845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-899-9787
Provider Business Practice Location Address Fax Number:
972-899-9786
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DELL
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
GUYTON
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
972-899-9787

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  K8697 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367A00000X , with the licence number: 536369 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 151884703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D1042013 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0065MT . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180279501 . This is a "MEDICAID GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10007551 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7215354 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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