1790881621 NPI number — PATRICIA M MCCORMICK DUPRE CRNA

Table of content: PATRICIA M MCCORMICK DUPRE CRNA (NPI 1790881621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790881621 NPI number — PATRICIA M MCCORMICK DUPRE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK DUPRE
Provider First Name:
PATRICIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUPRE
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790881621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 714813
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-293-0247
Provider Business Mailing Address Fax Number:
937-293-0960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LIMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45804-4099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-224-7586
Provider Business Practice Location Address Fax Number:
419-224-9769
Provider Enumeration Date:
09/16/2006

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: 367500000X , with the licence number:  037246 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN149531 , 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: 0583328 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2135684 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000515999 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 037246 . This is a "CRNA LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 746241 . This is a "BUCKEYE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000226089 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 414347 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7441733 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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