1154618528 NPI number — DR. JENNIFER V SEIBERT OD

Table of content: DR. JENNIFER V SEIBERT OD (NPI 1154618528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154618528 NPI number — DR. JENNIFER V SEIBERT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEIBERT
Provider First Name:
JENNIFER
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VIRAG
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154618528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3490 DAMASCUS CHURCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29020-9188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-650-4515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1057 BROAD ST
Provider Second Line Business Practice Location Address:
#48
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-775-8951
Provider Business Practice Location Address Fax Number:
803-775-8955
Provider Enumeration Date:
07/06/2011

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: 152W00000X , with the licence number:  2011020051 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: 2011020051 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 2011020051 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1717 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1154618528 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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