1073564993 NPI number — MARK JAMES JAMESON MD PHD

Table of content: DR. GIDEON BURIAN DPM (NPI 1992742704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073564993 NPI number — MARK JAMES JAMESON MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAMESON
Provider First Name:
MARK
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HORNEY
Provider Other First Name:
MARK
Provider Other Middle Name:
JAMES
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073564993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1417 S CLIFF AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-1062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-504-3000
Provider Business Mailing Address Fax Number:
605-504-3001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 S CLIFF AVE STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-504-3000
Provider Business Practice Location Address Fax Number:
605-504-3001
Provider Enumeration Date:
05/15/2006

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: 207Y00000X , with the licence number:  0101241309 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 13192 , 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: 0487819 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1073564993 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00347197 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 20003 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".