1629072129 NPI number — CITY OF IDALOU

Table of content: (NPI 1629072129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629072129 NPI number — CITY OF IDALOU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF IDALOU
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:
1629072129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1277
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDALOU
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79329-1277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-473-0927
Provider Business Mailing Address Fax Number:
832-877-5040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDALOU
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-473-0927
Provider Business Practice Location Address Fax Number:
832-877-5040
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
MASCHA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MGR
Authorized Official Telephone Number:
903-473-0927

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00104241 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 000015001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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