1366468175 NPI number — MRS. LAURA L TALLMAN DPT

Table of content: MRS. LAURA L TALLMAN DPT (NPI 1366468175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366468175 NPI number — MRS. LAURA L TALLMAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TALLMAN
Provider First Name:
LAURA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIBERATORE
Provider Other First Name:
LAURA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366468175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 NEW FIDELITY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529-2665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-258-2714
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2634 BRANDERMILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAMBRILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-721-7201
Provider Business Practice Location Address Fax Number:
410-721-7580
Provider Enumeration Date:
07/14/2006

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: 225100000X , with the licence number:  20652 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 619265-04 . This is a "CAREFIRST BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 80286700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51200008 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: F8710005 . This is a "CAREFIRST BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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