1568834893 NPI number — MS. BRAELEN DAWN IVICEVICH PA-C

Table of content: MS. BRAELEN DAWN IVICEVICH PA-C (NPI 1568834893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568834893 NPI number — MS. BRAELEN DAWN IVICEVICH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVICEVICH
Provider First Name:
BRAELEN
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1568834893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6560 FANNIN, SCURLOCK TOWER
Provider Second Line Business Mailing Address:
SUITE 2200
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-737-4560
Provider Business Mailing Address Fax Number:
281-737-4561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6560 FANNIN
Provider Second Line Business Practice Location Address:
SCURLOCK TOWER, SUITE 2200
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-737-4560
Provider Business Practice Location Address Fax Number:
281-737-4561
Provider Enumeration Date:
10/26/2015

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: 363AS0400X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8266NT . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1568834893 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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