1902862634 NPI number — ROGER CASADY MD

Table of content: ROGER CASADY MD (NPI 1902862634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902862634 NPI number — ROGER CASADY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASADY
Provider First Name:
ROGER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1902862634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 CARTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERRYVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72616-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-423-3338
Provider Business Practice Location Address Fax Number:
870-423-7330
Provider Enumeration Date:
04/21/2006

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: 208600000X , with the licence number:  E-3204 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1902862634 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5M086C895 . This is a "AR MCR GROUP #5C895" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 145897001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00653981 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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