1245255934 NPI number — DR. MAUREEN A BOYLE-MANGANARO MD

Table of content: DR. MAUREEN A BOYLE-MANGANARO MD (NPI 1245255934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245255934 NPI number — DR. MAUREEN A BOYLE-MANGANARO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYLE-MANGANARO
Provider First Name:
MAUREEN
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1245255934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3755
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68103-0755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-354-2100
Provider Business Mailing Address Fax Number:
402-354-2155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 RIDGE ST
Provider Second Line Business Practice Location Address:
STE 312
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-396-7880
Provider Business Practice Location Address Fax Number:
712-396-7885
Provider Enumeration Date:
07/13/2006

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: 207V00000X , with the licence number:  28036 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 2001005627 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X , with the licence number: MD-43345 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 465449 . This is a "CHILDRENS MERCY FAMILY HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 47068731777 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 476709 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00036242 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 414770 . This is a "FIRSTGUARD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44054528964506V018 . This is a "TRICARE/CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5897653 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10001545401 . This is a "COMMUNITY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100402030B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245255934 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026301600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 29689029 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 10026211300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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