1538213491 NPI number — JACQUELINE D ADLER, MD, LLC

Table of content: (NPI 1538213491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538213491 NPI number — JACQUELINE D ADLER, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELINE D ADLER, MD, LLC
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:
1538213491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERIDAN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82801-1446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-674-0700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 W 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SHERIDAN
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82801-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-674-0700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ADLER
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
307-674-0700

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  7081A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 313871 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 121742900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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