1639135437 NPI number — BRANDON W COVERT DO

Table of content: BRANDON W COVERT DO (NPI 1639135437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639135437 NPI number — BRANDON W COVERT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COVERT
Provider First Name:
BRANDON
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1639135437
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64803-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-347-6611
Provider Business Mailing Address Fax Number:
417-347-6662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 W 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-3503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-6611
Provider Business Practice Location Address Fax Number:
417-347-6662
Provider Enumeration Date:
04/21/2006

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: 2085R0202X , with the licence number:  2019024227 , 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: 843471 . This is a "BCBS KS FOR MO LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200346940D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00364462 . This is a "RR MEDICARE GROUP CK7871" identifier . This identifiers is of the category "OTHER".
  • Identifier: 106093 . This is a "BCBS KS FOR KS LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 207364902 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35466021 . This is a "BCBS OF KC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 107196700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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