1255470100 NPI number — MS. BEVERLY LAVON MCNEIL PAC

Table of content: WILLIAM D ELLIS M.D. (NPI 1790050128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255470100 NPI number — MS. BEVERLY LAVON MCNEIL PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCNEIL
Provider First Name:
BEVERLY
Provider Middle Name:
LAVON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1255470100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1265 EDDY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT TOWNSEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98368-9216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-385-9730
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 BOGACHIEL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORKS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98331-9120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-374-6271
Provider Business Practice Location Address Fax Number:
360-374-6238
Provider Enumeration Date:
02/06/2007

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: 363A00000X , with the licence number:  PA10004657 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2334MC . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8389975 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0188321 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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