1902912009 NPI number — STACI LOUISE WHITSON PT

Table of content: MS. CHRISTINE H SUH PHARM.D. (NPI 1912038944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902912009 NPI number — STACI LOUISE WHITSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITSON
Provider First Name:
STACI
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUDD
Provider Other First Name:
STACI
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902912009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 RED MAPLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52214-9537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-350-6990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 RED MAPLE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRAL CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52214-9537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-350-6990
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2006

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: 225100000X , with the licence number:  02696 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 421494864 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 421494864 . This is a "MIDLANDS CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 421494864 . This is a "ACCOUNTABLE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 421494864 . This is a "FIRST HEALTH MAIL HANDLER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42149864 . This is a "PRIVATE HEALTH CARE SYSTE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7202080 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0100 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06745 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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