1811131311 NPI number — DR. GARY M IDELCHIK M.D.

Table of content: DR. GARY M IDELCHIK M.D. (NPI 1811131311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811131311 NPI number — DR. GARY M IDELCHIK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IDELCHIK
Provider First Name:
GARY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1811131311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 E 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82601-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-266-3174
Provider Business Mailing Address Fax Number:
307-266-3177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-266-3174
Provider Business Practice Location Address Fax Number:
307-266-3177
Provider Enumeration Date:
04/28/2009

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: 207RI0011X , with the licence number:  ME133430 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 259398 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 13381A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 157420500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102451000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03824182 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102451000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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