1992700413 NPI number — DR. EDWARD JOHN BRANDECKER M.D.

Table of content: MICHAEL STEVENS (NPI 1235825449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992700413 NPI number — DR. EDWARD JOHN BRANDECKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDECKER
Provider First Name:
EDWARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1992700413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1888 ANTILLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79606-5205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-795-9550
Provider Business Mailing Address Fax Number:
325-795-9537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1888 ANTILLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABILENE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79606-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-795-9550
Provider Business Practice Location Address Fax Number:
325-795-9537
Provider Enumeration Date:
06/21/2005

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: 208100000X , with the licence number:  J2508 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: J2508 , 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: 4223641 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8X7151 . This is a "BCBS/ADC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 102408501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109067104 . This is a "FIRSTCARE/ADC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 81T422 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102408503 . This is a "MEDICAID/ADC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 109067100 . This is a "FIRSTCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CR1046 . This is a "MCR RXR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 250003414 . This is a "MEDICARE RR" identifier . This identifiers is of the category "OTHER".




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