1457416257 NPI number — ROGER O BRICK DC

Table of content: ROGER O BRICK DC (NPI 1457416257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457416257 NPI number — ROGER O BRICK DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRICK
Provider First Name:
ROGER
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1457416257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 CLAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64601-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-646-6044
Provider Business Mailing Address Fax Number:
660-646-6048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 CLAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILLICOTHEE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64601-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-646-6044
Provider Business Practice Location Address Fax Number:
660-646-6048
Provider Enumeration Date:
12/22/2006

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: 111N00000X , with the licence number:  003768 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04741014 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 10001319001 . This is a "COMMUNITY HEALTH CHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5078241 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 350000892 . This is a "UNITED HEALTHCARE RAILROA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com