1154496875 NPI number — MRS. JILL A SIPPOS MPT

Table of content: MRS. JILL A SIPPOS MPT (NPI 1154496875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154496875 NPI number — MRS. JILL A SIPPOS MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIPPOS
Provider First Name:
JILL
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

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:
1154496875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1685 TEMPEST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59718-6107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-655-0317
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8757 JACKRABBIT LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELGRADE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59714-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-388-8118
Provider Business Practice Location Address Fax Number:
406-388-9916
Provider Enumeration Date:
11/21/2006

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: 225100000X , with the licence number:  5312192-2401 , 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: D5297 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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