1053452490 NPI number — DR. JON TIMOTHY TRUMAN DC

Table of content: BROOKE MCDERMOTT RBT (NPI 1902562358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053452490 NPI number — DR. JON TIMOTHY TRUMAN DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRUMAN
Provider First Name:
JON
Provider Middle Name:
TIMOTHY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1053452490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43450-0415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-287-3216
Provider Business Mailing Address Fax Number:
419-287-3216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 E FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43450-0415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-287-3216
Provider Business Practice Location Address Fax Number:
419-287-3216
Provider Enumeration Date:
02/09/2007

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: 111N00000X , with the licence number:  50 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000127623 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341121454003 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 02785 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34112145400 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0197586 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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