1639242621 NPI number — W.V. FATTIG M.D.

Table of content: (NPI 1639242621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639242621 NPI number — W.V. FATTIG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W.V. FATTIG M.D.
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:
1639242621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
723 FLACK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLIANCE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69301-3514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-225-4498
Provider Business Mailing Address Fax Number:
308-646-0341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
723 FLACK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLIANCE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69301-3514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-225-4498
Provider Business Practice Location Address Fax Number:
308-646-0341
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FATTIG
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
308-225-4498

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  21201 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21201 . This is a "STATE LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 28D1030805 . This is a "CLIA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 507843624 . This is a "SS#" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: P00181202 . This is a "RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 04137 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025150600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35808 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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