1366501876 NPI number — DR. ROBERT LOREN BRIDGES M.D.

Table of content: DR. ROBERT LOREN BRIDGES M.D. (NPI 1366501876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366501876 NPI number — DR. ROBERT LOREN BRIDGES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIDGES
Provider First Name:
ROBERT
Provider Middle Name:
LOREN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1366501876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GIRDWOOD
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-382-0952
Provider Business Mailing Address Fax Number:
866-305-3886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 E. GARDNER WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-357-1220
Provider Business Practice Location Address Fax Number:
907-357-1222
Provider Enumeration Date:
12/08/2006

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: 2085R0202X , with the licence number:  4098 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085N0904X , with the licence number: 4098 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: MDG1553 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDG1551 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: N2018 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: MDG1552 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4098 . This is a "STATE OF AK MEDICAL LICEN" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: MD5606 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDG155 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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