1417138116 NPI number — SURGERY ADULT PEDIATRIC VASCULAR P.C.

Table of content: (NPI 1417138116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417138116 NPI number — SURGERY ADULT PEDIATRIC VASCULAR P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGERY ADULT PEDIATRIC VASCULAR P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1417138116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
HASTINGS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68902-0249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-462-2330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 N KANSAS AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68901-2615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-462-2330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARTH
Authorized Official First Name:
GARY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-462-5555

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  14009 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04256 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 2009 . This is a "MIDLAND CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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