1083628721 NPI number — FRANK MICUCCI MPA-C

Table of content: FRANK MICUCCI MPA-C (NPI 1083628721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083628721 NPI number — FRANK MICUCCI MPA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICUCCI
Provider First Name:
FRANK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPA-C
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:
1083628721
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 S ROOSEVELT AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52601-1668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-768-4320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 S ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52601-1668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-768-4320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 17518 . This is a "WELLMARK BLUE CROSS BLUE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 4554 . This is a "MIDLANDS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 970014324 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 168951 . This is a "RH MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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