1386725349 NPI number — PAMELA V NOLL PHD

Table of content: PAMELA V NOLL PHD (NPI 1386725349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386725349 NPI number — PAMELA V NOLL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOLL
Provider First Name:
PAMELA
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1386725349
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3872 E HARBOR LIGHT LANDING DR
Provider Second Line Business Mailing Address:
SUITE 221
Provider Business Mailing Address City Name:
PORT CLINTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43452-3877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-734-3333
Provider Business Mailing Address Fax Number:
877-734-2030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30432 EUCLID AVE
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
WICKLIFFE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44092-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-585-4500
Provider Business Practice Location Address Fax Number:
330-499-2536
Provider Enumeration Date:
10/18/2006

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: 103TC0700X , with the licence number:  5343 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6100374 . This is a "EVERCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 680009560 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 92895 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000137855 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 290600000 . This is a "MAGELLAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2060157 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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