1871521567 NPI number — PAUL A REDER M.D.

Table of content: PAUL A REDER M.D. (NPI 1871521567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871521567 NPI number — PAUL A REDER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDER
Provider First Name:
PAUL
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1871521567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84660-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-822-2234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34910 INTERSTATE 10 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006-9229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-994-4880
Provider Business Practice Location Address Fax Number:
361-994-4890
Provider Enumeration Date:
06/29/2006

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: 207Y00000X , with the licence number:  101249 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: J7153 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100262986 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1353229-12 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135322913 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8BR082 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8S4592 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 135322914 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135322916 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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