1306908280 NPI number — MR. ROBERT JAMES DEGOOYER NBC HIS

Table of content: MR. ROBERT JAMES DEGOOYER NBC HIS (NPI 1306908280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306908280 NPI number — MR. ROBERT JAMES DEGOOYER NBC HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGOOYER
Provider First Name:
ROBERT
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NBC HIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEGOOYER
Provider Other First Name:
JIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NBC HIS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306908280
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:
607 SOUTH CARROLL STREET
Provider Second Line Business Mailing Address:
P O BOX 243
Provider Business Mailing Address City Name:
PARK RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51246-0243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-472-3698
Provider Business Mailing Address Fax Number:
712-472-3698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 SOUTH CARROLL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51246-0243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-472-3698
Provider Business Practice Location Address Fax Number:
712-472-3698
Provider Enumeration Date:
12/15/2006

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: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0035121 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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