1801846704 NPI number — DR. STEPHEN BERNARD REZNICEK MD

Table of content: PEGGI RYAN FNP (NPI 1366419582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801846704 NPI number — DR. STEPHEN BERNARD REZNICEK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REZNICEK
Provider First Name:
STEPHEN
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1801846704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-779-2565
Provider Business Mailing Address Fax Number:
231-775-0744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 NORTH H STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-537-6470
Provider Business Practice Location Address Fax Number:
360-537-6475
Provider Enumeration Date:
05/11/2006

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: 208800000X , with the licence number:  MC-0557 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X , with the licence number: 062640 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 297815510 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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