1184811796 NPI number — ANDREW F BROOKER M.D.

Table of content: (NPI 1184811796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184811796 NPI number — ANDREW F BROOKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREW F BROOKER M.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1184811796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4514 CORNELL ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79109-5800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-355-6552
Provider Business Mailing Address Fax Number:
806-468-0340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4514 CORNELL ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79109-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-355-6552
Provider Business Practice Location Address Fax Number:
806-468-0340
Provider Enumeration Date:
09/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
806-468-0313

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X , with the licence number:  J5961 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W1786 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142946601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK2090 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00942N . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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