1629638184 NPI number — RICHARD GERARD BRODMERKEL PEER ADVOCATE

Table of content: RICHARD GERARD BRODMERKEL PEER ADVOCATE (NPI 1629638184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629638184 NPI number — RICHARD GERARD BRODMERKEL PEER ADVOCATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODMERKEL
Provider First Name:
RICHARD
Provider Middle Name:
GERARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PEER ADVOCATE
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:
1629638184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 E DESERT INN RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89169-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-208-2194
Provider Business Mailing Address Fax Number:
702-208-2208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 E DESERT INN RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89169-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-208-2194
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2019

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: 175T00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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