1336115609 NPI number — ELAINE G HEADRICK CNP

Table of content: ELAINE G HEADRICK CNP (NPI 1336115609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336115609 NPI number — ELAINE G HEADRICK CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEADRICK
Provider First Name:
ELAINE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1336115609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S. MINNESOTA AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 E. 20TH ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-3455
Provider Business Practice Location Address Fax Number:
605-322-3456
Provider Enumeration Date:
02/27/2006

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: 363LW0102X , with the licence number:  0271 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 230278 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 28563 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 370624200 . This is a "DEPT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 67B26HE . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 140309 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 57105E002 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: AH1451026885 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0007481 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: HP37108 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6826982 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0585661 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194219 . This is a "ARAZ/ AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 579152900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0701587 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 10025120100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 67B26HE . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 500016956 . This is a "RR MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9240518 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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