1659404978 NPI number — MRS. GLENDA FRANCES FITZGERALD

Table of content: MRS. GLENDA FRANCES FITZGERALD (NPI 1659404978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659404978 NPI number — MRS. GLENDA FRANCES FITZGERALD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
GLENDA
Provider Middle Name:
FRANCES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
GLENDA
Provider Other Middle Name:
BARLEY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1659404978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
739 GILES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63379-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-528-6507
Provider Business Mailing Address Fax Number:
636-528-2411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 W COLLEGE ST
Provider Second Line Business Practice Location Address:
TROY R-III
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63379-1112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-462-6098
Provider Business Practice Location Address Fax Number:
636-528-2411
Provider Enumeration Date:
03/14/2007

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: 235Z00000X , with the licence number:  111521 , 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: 467752002 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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