1770601874 NPI number — WAYNE TUCKER DO, PA

Table of content: (NPI 1770601874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770601874 NPI number — WAYNE TUCKER DO, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE TUCKER DO, PA
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:
1770601874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BECKS WOODS DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BEAR
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-838-1100
Provider Business Mailing Address Fax Number:
302-838-8962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BECKS WOODS DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BEAR
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19701-3835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-838-1100
Provider Business Practice Location Address Fax Number:
302-838-8962
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
IRA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
302-838-1100

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  F1-0000484 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: C2004133 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0001131503 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0100579 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1770601874 . This is a "BCBS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 116893 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 4331251 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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