1629130075 NPI number — WILLIAM J KNOFLICEK PH.D.

Table of content: WILLIAM J KNOFLICEK PH.D. (NPI 1629130075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629130075 NPI number — WILLIAM J KNOFLICEK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOFLICEK
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNOFLICEK
Provider Other First Name:
WILLIAM
Provider Other Middle Name:
J.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629130075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S. MINNESOTA AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 69TH ST
Provider Second Line Business Practice Location Address:
STE. 500
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-8171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-7580
Provider Business Practice Location Address Fax Number:
605-322-7579
Provider Enumeration Date:
12/14/2006

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: 103T00000X , with the licence number:  461 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 46022474326 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4993504 . This is a "WELLMARK BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9236559 . This is a "DAKOTACARE PROV #" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 247052700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6552352 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99GO9KN . This is a "MN BLUE CROSS PROV #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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