1598767113 NPI number — MR. JEFFREY DAVID TABER MD

Table of content: MR. JEFFREY DAVID TABER MD (NPI 1598767113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598767113 NPI number — MR. JEFFREY DAVID TABER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TABER
Provider First Name:
JEFFREY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1598767113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
591 2ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDOM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56101-1927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-831-2223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2005

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: 207Q00000X , with the licence number:  33708 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135203200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: NA3221016530 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1506584 . This is a "IA MEDICAID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112159 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 33246WI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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