1053446443 NPI number — BETH BRUENING PC

Table of content: (NPI 1053446443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053446443 NPI number — BETH BRUENING PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETH BRUENING PC
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:
1053446443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3566
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51102-3566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-217-4500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 TOWER ROAD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
DAKOTA DUNES
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-217-4500
Provider Business Practice Location Address Fax Number:
605-217-4503
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
605-217-4500

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  650 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 28135 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 3577 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025498700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7760323 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2072876 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025636300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3577 . This is a "SD LIC" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 28135 . This is a "IA LIC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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