1063577765 NPI number — S A GABRIEL DO INC

Table of content: (NPI 1063577765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063577765 NPI number — S A GABRIEL DO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S A GABRIEL DO INC
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:
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:
1063577765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45405-4139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-278-8244
Provider Business Mailing Address Fax Number:
937-274-8982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8701 OLD TROY PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45424-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-278-8244
Provider Business Practice Location Address Fax Number:
937-274-8982
Provider Enumeration Date:
12/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
937-278-8244

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  34003827 , 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: 0701593 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720129 . This is a "UHC #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 020044283 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 284564686 . This is a "TRICARE PROVIDER #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000005821 . This is a "BS & ANTHEM #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 284564686001 . This is a "MEDICAL MUTUAL PROVIDER #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 28456468600 . This is a "BWC PROVIDER #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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