1073628129 NPI number — MARSHA L MEINERS PA-C

Table of content: S TAYLOR GARNETT D.D.S (NPI 1841210465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073628129 NPI number — MARSHA L MEINERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEINERS
Provider First Name:
MARSHA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIDER
Provider Other First Name:
MARSHA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073628129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-0577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-985-8221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 WILDCAT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-969-8228
Provider Business Practice Location Address Fax Number:
618-998-0880
Provider Enumeration Date:
08/20/2006

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: 363A00000X , with the licence number:  085-000677 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101081 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370966854023 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640701 . This is a "PTAN MEDICAARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CF3444 . This is a "MEDICARE RR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370966854014 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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