1902874480 NPI number — DR. COREY H TABBERT OD

Table of content: DR. COREY H TABBERT OD (NPI 1902874480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902874480 NPI number — DR. COREY H TABBERT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TABBERT
Provider First Name:
COREY
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1902874480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 1ST ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADENA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56482-1567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-631-2020
Provider Business Mailing Address Fax Number:
218-631-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 SE FIRST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADENA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-631-2020
Provider Business Practice Location Address Fax Number:
218-631-1892
Provider Enumeration Date:
03/09/2006

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: 152W00000X , with the licence number:  2883 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 365T9TA . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP36359 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1032301 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 365T9TA . This is a "SOUTH COUNTY HEALTH ALLIANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02149 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 365T9TA . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410002031 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 999995765 . This is a "VSP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MN2883 . This is a "EYEMED" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com