1841317872 NPI number — MR. RICHARD B LUYSTER P.T.

Table of content: MR. RICHARD B LUYSTER P.T. (NPI 1841317872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841317872 NPI number — MR. RICHARD B LUYSTER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUYSTER
Provider First Name:
RICHARD
Provider Middle Name:
B
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1841317872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77101 DOUGLAS TURN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREEPORT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43973-9372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-491-0791
Provider Business Mailing Address Fax Number:
866-274-4974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77101 DOUGLAS TURN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43973-9372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-491-0791
Provider Business Practice Location Address Fax Number:
866-274-4974
Provider Enumeration Date:
03/23/2007

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: 225100000X , with the licence number:  PT-08819 , 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: 020579400-00 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2209069 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000226050 . This is a "ANTHEM BC BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0205794001A00 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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