1265490122 NPI number — NEMESIO E GUTIERREZ

Table of content: NEMESIO E GUTIERREZ (NPI 1265490122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265490122 NPI number — NEMESIO E GUTIERREZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
NEMESIO
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1265490122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7687
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65205-7687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-882-2259
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 BUSINESS LOOP 70 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203-2546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-884-1400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2006

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: 2084P0800X , with the licence number:  MDR4H80 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114225 . This is a "BLUE SHIELD/BLUE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 33468547 . This is a "ILLINOIS MEDICAID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1500107 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 260035875 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: K51B502 . This is a "KANSAS MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 202694121 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 342200 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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