1902881733 NPI number — RICK CORBETT CRNA

Table of content: RICK CORBETT CRNA (NPI 1902881733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902881733 NPI number — RICK CORBETT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORBETT
Provider First Name:
RICK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1902881733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ANDRA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62062-5796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-343-0048
Provider Business Mailing Address Fax Number:
618-343-0048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62040-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-343-0048
Provider Business Practice Location Address Fax Number:
618-343-0048
Provider Enumeration Date:
12/14/2005

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: 367500000X , with the licence number:  209002579 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 28184077A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000946369 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200938570 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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