1598788507 NPI number — VICTORIA RUTH BUCKNER DO

Table of content: GRACE CAROLINE HALVORSEN (NPI 1346021748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598788507 NPI number — VICTORIA RUTH BUCKNER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKNER
Provider First Name:
VICTORIA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1598788507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6661 CLYO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-425-4000
Provider Business Mailing Address Fax Number:
937-425-4002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 LEITER RD
Provider Second Line Business Practice Location Address:
SYCAMORE PRIMARY CARE GROUP
Provider Business Practice Location Address City Name:
MIAMISBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45342-3659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-384-6800
Provider Business Practice Location Address Fax Number:
937-384-6939
Provider Enumeration Date:
07/25/2006

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: 207R00000X , with the licence number:  2006-01029 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 34009103 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 190798 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 808057 . This is a "PARTNERS MEDICARE CH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7345780 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 190798 . This is a "MEDCOST ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 14214 . This is a "BCBS ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00328842 . This is a "RAILROAD MEDICARE ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 14214 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2767439 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5904460 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 566000156 . This is a "PRATICE TAX ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7345780 . This is a "AETNA ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 808057 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 311446216 . This is a "PRACTICE TAX ID #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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