1851328710 NPI number — CASE RUCKMAN DCPC

Table of content: (NPI 1851328710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851328710 NPI number — CASE RUCKMAN DCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASE RUCKMAN DCPC
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:
6
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:
1851328710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 267
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-868-0818
Provider Business Mailing Address Fax Number:
660-726-5285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 W. CLAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-726-3322
Provider Business Practice Location Address Fax Number:
660-726-5285
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUCKMAN
Authorized Official First Name:
CASE
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
OWNER - AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
816-244-3789

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  004598 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500078273 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11297016 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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