1891872719 NPI number — DIANNE M. GREJTAK

Table of content: (NPI 1891872719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891872719 NPI number — DIANNE M. GREJTAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIANNE M. GREJTAK
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:
MEDICAL SPECIALTY SHOPPE
Provider Other Organization Name Type Code:
3
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:
1891872719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4944 RESEARCH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-5006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-614-3360
Provider Business Mailing Address Fax Number:
210-614-3362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4944 RESEARCH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-5006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-614-3360
Provider Business Practice Location Address Fax Number:
210-614-3362
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREJTAK
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-614-3360

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0065742 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 0065742 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0007451364 . This is a "AETNA TRS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 531788 . This is a "BCBS FEDERAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 155364601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 531788 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 190990121250 . This is a "HUMANA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 155364602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4037010 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 585599 . This is a "BCBS KS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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