1659446698 NPI number — JULIE ANN MACKALL OD

Table of content: JULIE ANN MACKALL OD (NPI 1659446698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659446698 NPI number — JULIE ANN MACKALL OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACKALL
Provider First Name:
JULIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OLINGER
Provider Other First Name:
JULIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659446698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 SOUTHEAST BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44460-3482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-332-4501
Provider Business Mailing Address Fax Number:
330-332-4540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 SOUTHEAST BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-332-4501
Provider Business Practice Location Address Fax Number:
330-332-4540
Provider Enumeration Date:
11/22/2006

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: 152W00000X , with the licence number:  5492 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000350487 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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