1093703530 NPI number — DR. JAMES A WOODMANSEE III M.D.

Table of content: DR. JAMES A WOODMANSEE III M.D. (NPI 1093703530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093703530 NPI number — DR. JAMES A WOODMANSEE III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODMANSEE
Provider First Name:
JAMES
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
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:
1093703530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 N UNIVERSITY PKWY
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-377-3413
Provider Business Mailing Address Fax Number:
801-655-1890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 N UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-377-3413
Provider Business Practice Location Address Fax Number:
801-655-1940
Provider Enumeration Date:
10/10/2005

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: 207Q00000X , with the licence number:  1817981205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 308184 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1093703530 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000057007 . This is a "MEDICARE ID PIN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107007064102 . This is a "SELECTHEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 0100642 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000000779 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 4584585 . This is a "AETNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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