1619059417 NPI number — AVALON OBSTETRICS AND GYNECOLOGY, P.C.

Table of content: (NPI 1619059417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619059417 NPI number — AVALON OBSTETRICS AND GYNECOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON OBSTETRICS AND GYNECOLOGY, P.C.
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:
1619059417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 W LIBERTY ST
Provider Second Line Business Mailing Address:
SUITE 2050
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63640-1921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-701-9600
Provider Business Mailing Address Fax Number:
573-701-9605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 W LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 2050
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63640-1921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-701-9600
Provider Business Practice Location Address Fax Number:
573-701-9605
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNIDER
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
573-701-9600

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  R9B54 , 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: DD7351 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 241676840 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com