ab

NPI Entity Type Code Replacement NPI Employer Identification Number (EIN)
1679576722 1
1588667638 1
1497758544 2 <UNAVAIL>
1306849450
1215930367 1
1023011178 2 <UNAVAIL>
1932102084 1
1841293990 1
1750384806 1
1669475711 1
1578566626 1
1487657532 1
1396748448 1
1205839354 1
1114920261 1
1023011079 2 <UNAVAIL>
1932102985 1
1841293891 1
1750384707 1
1669475612 1
1578566527 1
1487657433 2 <UNAVAIL>
1396748349 1
1205839255 1
1114920162 1
1922001973 1
1831192889 1
1740283795 2 <UNAVAIL>
1659374601 1
1568465516 1
1477556421 1
1255334207 1
1164425112 1
1073516027 1
1982607933 2 <UNAVAIL>
1891798849
1700889755 2 <UNAVAIL>
1619970662 1
1427051473 2 <UNAVAIL>
1336142389 2 <UNAVAIL>
1245233295 1
1962405910 2 <UNAVAIL>

Page 1
 ab

Provider Organization Name (Legal Business Name) Provider Last Name (Legal Name)
WIEBE
PILCHER
CUMBERLAND COUNTY HOSPITAL SYSTEM, INC

GRESSOT
COLLABRIA CARE
ADUSUMILLI
WORTSMAN
BISBEE
SUNG
KUIPERS
HUEBERT
YOUNG-MAYKA
DIFILIPPO
THACKER
ADVANTAGE HOME HEALTH CARE, INC.
ROTHSTEIN
GIBBS
MARKMAN
TROTCHIE
DYSART
PEKIN MRI, LLC
GRUNERT
GOLDBERG
DUBOSE
ANDERSON-KRULL
COE
EASTERN STAR MASONIC HOME
OBERDICK
SALENGER
ROTH
SOUCIER
ISETTS
CHANG
ADR LLC

AZAR/FILIPOV MD PA
FRIEDMAN
OAKVIEW MEDICAL CARE FACILITY
ADIRONDACK MEDICAL HEALTH CARE ASSOCIATES PLLC
POTTS
ALABAMA CARDIOVASCULAR GROUP, P.C.

Page 2
 ab

Provider First Name Provider Middle Name Provider Name Prefix Text Provider Name Suffix Text
DAVID A
WILLIAM C DR.

LAURENT DR.

RAVI K
SUSAN
ROBERT DR.
BIN SHENG
WARREN D.
ALLISON L DR.
CYNTHIA J MS.
EMIL A DR.
RICHARD RANDALL DR.

MARK TERRY DR.

ELMER RICKEY DR.
ALAN WILLIAM DR.
DEBRA CHARLENE
STANLEY H

GEORGE M DR.
STEVEN M DR.
JON DR.
TERESA MARY MS.
CRAIG L.

WENDY TIPTON
RAWN
STEVEN S. DR.
RICHARD
BRIAN JOHN DR.
JOHN CHU-HONG DR.

LISA AMY MRS.

JILL K DR.

Page 3
 ab

Provider Credential Text Provider Other Organization Name

M.D.
MD
CAPE FEAR VALLEY HOME HEALTH AND HOSPICE

M.D.
NAPA VALLEY HOSPICE & ADULT DAY SERVICES
MD
MA-CCC
MD
M. D.
MD
M.D.
P.A.
M.D.
D.O.

M.D.
M.D.
M.D.
APN
M.D.

M.D.
M.D.
MD
MSW LICSW
MD

MD
M.D.
O.D.
MD
B.C.P.S., PH.D.
M.D.

RN, MSN, CPNP

M.D.

Page 4
 ab

Provider Other Organization Name Type Code Provider Other Last Name Provider Other First Name

MUDDER DEBRA

TIPTON WENDY

Page 5
 ab

Provider Other Middle Name Provider Other Name Prefix Text Provider Other Name Suffix Text

NANETTE DR.

Page 6
 ab

Provider Other Credential Text Provider Other Last Name Type Code

MD 1

Page 7
 ab

Provider First Line Business Mailing Address

PO BOX 2168
1824 KING STREET
3418 VILLAGE DR

17323 RED OAK DR

414 S JEFFERSON ST
2940 N MCCORD RD
68 ROCKLEDGE RD
5219 CITY BANK PKWY STE 214
600 JEFFERSON ST STE 301
2929 E THOMAS RD
PO BOX 1330
100 METROPOLITAN DRIVE ASSOCIATED MEDICAL PROFESSIONALS
12639 OLD TESSON RD
2770 CAPITAL MEDICAL BLVD
425 E. US RT. 6
5450 FRANTZ RD STE 360
49 CLEVELAND ST 310
3800 PARK NICOLLET BLVD
8906 SPANISH RIDGE AVE STE 202
300 TOWER RD NE
1894 GEORGETOWN RD
7900 FANNIN ST STE 4000
1010 NORTHERN BLVD
111 HOSPITAL DR
216 E MAIN ST
210 WESTSIDE DR
715 W 3RD ST
PO BOX 9
257 LAFAYETTE AVE
1107 MANTUA PIKE
1000 ASYLUM AVE
3510 WILD TURKEY RD
169 N MIDDLETOWN RD
PO BOX 808

31519 WINTERPLACE PKWY

315 N SAN SABA
1001 DIANA ST
PO BOX 2004
335 PARRISH ST
2700 10TH AVE S

Page 8
 ab

Provider Second Line Business Mailing Address Provider Business Mailing Address City Name
KEARNEY
SUITE 300 JACKSONVILLE
FAYETTEVILLE

HOUSTON
NAPA
TOLEDO
APT 1C HARTSDALE
LUBBOCK
LAFAYETTE
PHOENIX
NORMAN
SUITE 200 LIVERPOOL
SAINT LOUIS
STE 200 TALLAHASSEE
SUITE F MORRIS
DUBLIN
CROSSVILLE
CREDENTIALING ST LOUIS PARK
LAS VEGAS
STE 200 MARIETTA
HUDSON
HOUSTON FERTILITY SPECIALISTS PLLC HOUSTON
STE 110 GREAT NECK
TARBORO
ALBERT LEA
DOTHAN
BOONE
KINGSPORT
SUITE 330 SUFFERN
STE 722 MANTUA
STE 4309 HARTFORD
RED WING
PEARL RIVER
CUMBERLAND

STE 1 SALISBURY
SUITE 1135 SAN ANTONIO
LUDINGTON
EAST SYRACUSE
CANANDAIGUA
STE 305 BIRMINGHAM

Page 9
 ab

Provider Business Mailing Address State Name

NE
FL
NC

TX
CA
OH
NY
TX
LA
AZ
OK
NY
MO
FL
IL
OH
TN
MN
NV
GA
OH
TX
NY
NC
MN
AL
IA
TN
NY
NJ
CT
MN
NY
MD

MD
TX
MI
NY
NY
AL

Page 10
 ab

Provider Business Mailing Address Postal Code

688482168
322044736
283044552

770901243
945594515
436151753
105303455
794073537
705016987
850168034
730701330
13088
631282786
323088417
604508812
430164141
385552854
554162527
891481319
300609403
442364058
770542935
110215306
278862011
560072919
363031928
500363930
376620009
109014830
80511606
61051770
550661765
109652029
215010808

218041884
782073154
494311908
130574504
144241728
352051248

Page 11
 ab

Provider Business Mailing Address Country Code (If outside U.S.)

US
US
US

US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US

US
US
US
US
US
US

Page 12
 ab

Provider Business Mailing Address Telephone Number Provider Business Mailing Address Fax Number
3088652512 3088652506
9043881820 9043881827
9106096740

2814405006 2814406149
7072589080 7072582476
4198423000 4198423048
2124814464
8067810360 8067820097
2813460018 2813460913
6024705000
4053076630 4053076660
3158709370 3157485358
3148490311 3148494423
8508788235 8502192373
8154671905 8154676392
6145446155 6145446370
9317871232 9317871228

7023303102 7029124994
7704275717 7704296503
3306533968 3306561660
7135127900 7135127829
5163902430 5164827955
2526417700 2526417313
5073770107 5073771194
3347935074 3347936460
5154325274 5154325276
4238572066 4238572070
8453688800 8453685608
8564649000 8564641577
8607146581 8607148311
6513858353
8457355666 8457355673
3017241646 3017247429

4105462500 4105465005
2107042190
2318455185 2318457957
3153625285 3154452936
5853932845 5853969275
2059390139 2059394997

Page 13
 ab

Provider First Line Business Practice Location Address

3500 CENTRAL AVE
1824 KING STREET
3418 VILLAGE DR

17323 RED OAK DR

414 S JEFFERSON ST
2940 N MCCORD RD
425 E 25TH ST
808 JOLIET AVE UNIT 120
7629 TIKI DR
1205 S 7TH AVE
3400 W TECUMSEH RD
806 WEST BROADWAY ASSOCIATED MEDICAL PROFESSIONALS
9323 PHOENIX VILLAGE PKWY
2770 CAPITAL MEDICAL BLVD
425 E. US RT. 6
75 HOSPITAL DR
49 CLEVELAND ST 310
8100 NORTHLAND DR
8876 SPANISH RIDGE AVE STE 103
300 TOWER RD NE
1300 PARK AVE
7900 FANNIN ST STE 4000
1010 NORTHERN BLVD
111 HOSPITAL DR
216 E MAIN ST
210 WESTSIDE DR
715 W 3RD ST
105 W STONE DR
7505 OSLER DR
1107 MANTUA PIKE
114 WOODLAND ST
308 HARVARD ST SE
169 N MIDDLETOWN RD
952 SETON DR

31519 WINTERPLACE PKWY

333 N SANTA ROSA
1001 DIANA ST
1656 CHAMPLIN AVE
335 PARRISH ST
2700 10TH AVE S

Page 14
 ab

Provider Second Line Business Practice Location Address

SUITE 300

SUITE 205
DICAL PROFESSIONALS

STE 200
SUITE F
SUITE 350

STE 200

HOUSTON FERTILITY SPECIALISTS PLLC

STE 110

STE 1F

STE 722

RM 7-175

STE 1

STE 305

Page 15
 ab

Provider Business Practice Location Address City Name

KEARNEY
JACKSONVILLE
FAYETTEVILLE

HOUSTON
NAPA
TOLEDO
NEW YORK
LUBBOCK
FULSHEAR
PHOENIX
NORMAN
FULTON
O FALLON
TALLAHASSEE
MORRIS
ATHENS
CROSSVILLE
MINNEAPOLIS
LAS VEGAS
MARIETTA
PEKIN
HOUSTON
GREAT NECK
TARBORO
ALBERT LEA
DOTHAN
BOONE
KINGSPORT
TOWSON
MANTUA
HARTFORD
MINNEAPOLIS
PEARL RIVER
CUMBERLAND

SALISBURY
SAN ANTONIO
LUDINGTON
NEW HARTFORD
CANANDAIGUA
BIRMINGHAM

Page 16
 ab

Provider Business Practice Location Address State Name

NE
FL
NC

TX
CA
OH
NY
TX
TX
AZ
OK
NY
MO
FL
IL
OH
TN
MN
NV
GA
IL
TX
NY
NC
MN
AL
IA
TN
MD
NJ
CT
MN
NY
MD

MD
TX
MI
NY
NY
AL

Page 17
 ab

Provider Business Practice Location Address Postal Code

688472944
322044736
283044552

770901243
945594515
436151753
100102547
794151148
774411548
850073913
730721810
13069
633664281
323088417
604508812
457012857
385552854
554314800
891481502
300609403
615545038
770542935
110215306
278862011
560072919
363031928
500363930
376603365
212047736
80511606
61051208
554550353
109652029
215021950

218041884
782073108
494311908
134131068
144241728
352051248

Page 18
 ab

Provider Business Practice Location Address Country Code (If outside U.S.)
US
US
US

US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US
US

US
US
US
US
US
US

Page 19
 ab

Provider Business Practice Location Address Telephone Number

3088652512
9043881820
9106096740

2814405006
7072589080
4198423000
2124814464
8067610540
2813460018
6023446600
4057932229
3152974700
6365615030
8508788235
8154671905
7405924491
9317871232
9528318742
7023420858
7704275717
3093472143
7135127900
5163902430
2526417700
5073770107
3347935074
5154325274
4232302420
4103371783
8564649000
8607144820
6126242140
8457355666
3017773522

4105462500
2107042190
2318455185
3156246222
5853932845
2059390139

Page 20
 ab

Provider Business Practice Location Address Fax Number Provider Enumeration Date
3088652506 05/23/2005
9043881827 05/23/2005
05/23/2005

2814406149 05/23/2005
7072582476 05/23/2005
4198423048 05/23/2005
05/23/2005
8067610451 05/23/2005
2813460913 05/23/2005
6023446601 05/23/2005
4059123579 05/23/2005
3152185898 05/23/2005
6365615033 05/23/2005
8502192373 05/23/2005
8154676392 05/23/2005
7405924844 05/23/2005
9317871228 05/23/2005
9528311626 05/23/2005
7023420858 05/23/2005
7704296503 05/23/2005
3093472416 05/23/2005
7135127829 05/23/2005
5164827955 05/23/2005
2526417313 05/23/2005
5073771194 05/23/2005
3347936460 05/23/2005
5154325276 05/23/2005
4232302422 05/23/2005
05/23/2005
8564641577 05/23/2005
8607148001 05/23/2005
6126259931 05/23/2005
8457355673 05/23/2005
3017771902 05/23/2005

4105465005 05/23/2005
05/23/2005
2318457957 05/23/2005
3156246308 05/23/2005
5853969275 05/23/2005
2059394997 05/23/2005

Page 21
 ab

Last Update Date NPI Deactivation Reason Code NPI Deactivation Date NPI Reactivation Date
07/08/2007
05/29/2014
09/26/2011
03/03/2021
11/25/2014
06/09/2020
04/23/2012
07/08/2007
03/10/2017
03/01/2020
02/12/2015
06/25/2013
01/26/2021
05/06/2015
08/20/2016
12/12/2014
12/24/2019
01/21/2016
03/05/2012
03/20/2021
12/05/2013
08/22/2020
09/03/2015
04/04/2011
10/07/2021
07/08/2007
07/09/2007
03/04/2008
10/20/2011 05/23/2005 05/24/2005
06/11/2021
07/08/2007
09/27/2016
07/08/2007
04/05/2017
08/16/2010
11/13/2017
03/30/2011
11/19/2020
10/26/2011
08/22/2020
07/08/2007
09/14/2015

Page 22
 ab

Provider Gender Code Authorized Official Last Name Authorized Official First Name
M
M
NAGOWSKI MICHAEL

M
ANDERSON DONALD
M
F
M
F
M
F
F
M
M
SLEETER KELLY
M
M
M
F
M
COYNE V.
M
M
M
F
M
BOCK DENNIS
F
M
M
M
M
M
KIM JONG

AZAR ALEX
F
WHITE NORMAN
FINLEY ANDREW
F
ARCINIEGAS JOAQUIN

Page 23
 ab

Authorized Official Middle Name Authorized Official Title or Position Authorized Official Telephone Number

CEO 9106096700

WAYNE ASSISTANT SECRETARY OF ENR 4255255392

JOHN ADMINISTRATOR 8154671905

RENAE DIRECTOR OF BILLING 3306533968

A. ADMINISTRATOR 5154325274

K PRESIDENT 3017241646

PRESIDENT 4105462500

J DIRECTOR OF FINANCIAL SERVIC 2318455185

L PRESIDENT 3156246222

G. PRESIDENT 2059390139

Page 24
 ab

Healthcare Provider Taxonomy Code_1 Provider License Number_1

207X00000X 12637
207RC0000X ME68414
251G00000X HC0283

174400000X H6257
251G00000X 100000741
207RC0000X 4301081344
231H00000X 000396-1
207R00000X J8461
208000000X J1405
207Q00000X 23525
207V00000X 21240
363A00000X 40721
207X00000X 30530
207R00000X MEOS6976
251E00000X 1008614
207Q00000X MD011535
208600000X 35733
174400000X 25873
363L00000X APRN00355
207X00000X 31591
293D00000X
207VE0102X E0945
207RC0000X 144482
208000000X 200101440
1041C0700X 2581
207R00000X 9845
314000000X N-0268
207Q00000X 200133
208G00000X 212244
152W00000X 27OA00378500
207RC0000X 33435
1835P1200X 113541-1
207W00000X 225687
174400000X

152W00000X
363LP0200X 662780
314000000X 2033624
207P00000X NA
207R00000X 210694
174400000X

Page 25
 ab

Provider License Number State Code_1 Healthcare Provider Primary Taxonomy Switch_1
NE Y
FL Y
NC Y

TX N
CA Y
MI N
NY Y
TX Y
TX Y
AZ Y
OK Y
NY Y
MO Y
FL Y
IL N
HI N
TN Y
MN Y
NV Y
GA Y
Y
TX Y
NY Y
NC N
MN Y
AL Y
IA N
LA N
MA N
NJ Y
CT Y
MN Y
NY Y
Y

N
TX N
MI N
NY Y
NY Y
Y

Page 26
 ab

Healthcare Provider Taxonomy Code_2 Provider License Number_2

207RC0000X 32024

207RH0003X H6257

207RC0000X 35069014

251E00000X 1011673
207Q00000X 35-037876
208G00000X 35733

207R00000X 200101440

311Z00000X R-268
207Q00000X MD200133
208G00000X 232808
152W00000X 27TO00030000
207RA0001X 33435

174400000X 225687-1

207W00000X
363LP0200X AP111980
314000000X 538510

Page 27
 ab

Provider License Number State Code_2 Healthcare Provider Primary Taxonomy Switch_2

GA N

TX Y

OH Y

IL Y
OH Y
TN N

NC Y

IA N
LA N
NY Y
NJ N
CT N

NY N

Y
TX Y
MI Y

Page 28
 ab

Healthcare Provider Taxonomy Code_3 Provider License Number_3

313M00000X N-0268
207Q00000X MD46567

Page 29
 ab

Provider License Number State Code_3 Healthcare Provider Primary Taxonomy Switch_3

IA Y
TN Y

Page 30
 ab

Healthcare Provider Taxonomy Code_4 Provider License Number_4

Page 31
 ab

Provider License Number State Code_4 Healthcare Provider Primary Taxonomy Switch_4

Page 32
 ab

Healthcare Provider Taxonomy Code_5 Provider License Number_5

Page 33
 ab

Provider License Number State Code_5 Healthcare Provider Primary Taxonomy Switch_5

Page 34
 ab

Healthcare Provider Taxonomy Code_6 Provider License Number_6

Page 35
 ab

Provider License Number State Code_6 Healthcare Provider Primary Taxonomy Switch_6

Page 36
 ab

Healthcare Provider Taxonomy Code_7 Provider License Number_7

Page 37
 ab

Provider License Number State Code_7 Healthcare Provider Primary Taxonomy Switch_7

Page 38
 ab

Healthcare Provider Taxonomy Code_8 Provider License Number_8

Page 39
 ab

Provider License Number State Code_8 Healthcare Provider Primary Taxonomy Switch_8

Page 40
 ab

Healthcare Provider Taxonomy Code_9 Provider License Number_9

Page 41
 ab

Provider License Number State Code_9 Healthcare Provider Primary Taxonomy Switch_9

Page 42
 ab

Healthcare Provider Taxonomy Code_10 Provider License Number_10

Page 43
 ab

Provider License Number State Code_10 Healthcare Provider Primary Taxonomy Switch_10

Page 44
 ab

Healthcare Provider Taxonomy Code_11 Provider License Number_11

Page 45
 ab

Provider License Number State Code_11 Healthcare Provider Primary Taxonomy Switch_11

Page 46
 ab

Healthcare Provider Taxonomy Code_12 Provider License Number_12

Page 47
 ab

Provider License Number State Code_12 Healthcare Provider Primary Taxonomy Switch_12

Page 48
 ab

Healthcare Provider Taxonomy Code_13 Provider License Number_13

Page 49
 ab

Provider License Number State Code_13 Healthcare Provider Primary Taxonomy Switch_13

Page 50
 ab

Healthcare Provider Taxonomy Code_14 Provider License Number_14

Page 51
 ab

Provider License Number State Code_14 Healthcare Provider Primary Taxonomy Switch_14

Page 52
 ab

Healthcare Provider Taxonomy Code_15 Provider License Number_15

Page 53
 ab

Provider License Number State Code_15 Healthcare Provider Primary Taxonomy Switch_15

Page 54
 ab

Other Provider Identifier_1 Other Provider Identifier Type Code_1 Other Provider Identifier State_1
645540 1 KS
00532485C 5 GA
3401562 5 NC

HPC01537G 5 CA
178623 5 OH

1270548 5 TX
325052 5 AZ
38436 1 OK
1270915 5 NY
45619 1
58464900 1 FL

259134 5 OH
3382060 5 TN

83047G 1 TX

891330U 5 NC
103903 1 MN

890210 5 IA
1520114 5 TN

2254417 5 NJ
1334359 5 CT

P00014839 1 NY
201927000 5 WV

63341100 5 MD

2085286 5 MI

6996 1 NY

Page 55
 ab

Other Provider Identifier Issuer_1 Other Provider Identifier_2 Other Provider Identifier Type Code_2
FIRSTGUARD 46969 1
510265 1

P00751116 1

BNDD BH6720381 1

CMR SP10135 1
MEDICAID GROUP 1114920261 5

RO0408502 1
27-1779467 1

BLUE CROSS & BLUE SHIELD

UCARE 131L4AN 1

801076 5
1623512 5

PALMETTO GBA RAILROAD MED 132998987 1

DA5555 1

BLUE SHIELD MDC741 1

Page 56
 ab

Other Provider Identifier State_2 Other Provider Identifier Issuer_2 Other Provider Identifier_3
KS BCBS 1553
GA BCBS 251286600

RAILROAD MEDICARE

OK DEA

CIGNA 4432V6097
GA 57188

MEDICARE PROVIDER NUMBER

TAX ID 4252798

MN BLUE SHIELD HP40008

IA
LA

NY TAX ID 2362274
RAILROAD MEDICARE 1586989

NY PREFERRED CARE 1859558

Page 57
 ab

Other Provider Identifier Type Code_3 Other Provider Identifier State_3 Other Provider Identifier Issuer_3
1 NE BCBS
5 FL

1 HEALTHCARE USA
1 FL INDIVIDUAL PROVIDER BCBS

1 TN BC/BS OF TN

1 MN HEALTH PARTNERS

5 NY
1 WV MT ST BS

5 NY

Page 58
 ab

Other Provider Identifier_4 Other Provider Identifier Type Code_4 Other Provider Identifier State_4

27888 1 FL

900093 1
P00625814 1 FL

4042486 1 TN

25801 1 MN

403741300 5 MD

Page 59
 ab

Other Provider Identifier Issuer_4 Other Provider Identifier_5 Other Provider Identifier Type Code_5

BCBS 208143 1

UHC 21646 1
MEDICARE RAILROAD 37822101 5

TENNCARE SELECT NUMBER

VMC BEHAVIORAL HEALTHCARE

J249 1

Page 60
 ab

Other Provider Identifier State_5 Other Provider Identifier Issuer_5 Other Provider Identifier_6

FL AVMED 00706626A

MO BLUE CROSS BLUE SHIELD 6034V3458

FL 99039

MD MD BLUE SHIELD 216A

Page 61
 ab

Other Provider Identifier Type Code_6 Other Provider Identifier State_6 Other Provider Identifier Issuer_6

5 GA

1 GHP/ADVANTRA
1 FL GROUP BCBS ID NUMBER

1 MD MD BLUE SHIELD

Page 62
 ab

Other Provider Identifier_7 Other Provider Identifier Type Code_7 Other Provider Identifier State_7

897705 1 FL

119066 1

Page 63
 ab

Other Provider Identifier Issuer_7 Other Provider Identifier_8 Other Provider Identifier Type Code_8

AETNA

HEALTHLINK 4061313 1

Page 64
 ab

Other Provider Identifier State_8 Other Provider Identifier Issuer_8 Other Provider Identifier_9

AETNA 9042

Page 65
 ab

Other Provider Identifier Type Code_9 Other Provider Identifier State_9 Other Provider Identifier Issuer_9

1 EXCLUSIVE CHOICE

Page 66
 ab

Other Provider Identifier_10 Other Provider Identifier Type Code_10 Other Provider Identifier State_10

Page 67
 ab

Other Provider Identifier Issuer_10 Other Provider Identifier_11 Other Provider Identifier Type Code_11

Page 68
 ab

Other Provider Identifier State_11 Other Provider Identifier Issuer_11 Other Provider Identifier_12

Page 69
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Other Provider Identifier Type Code_12 Other Provider Identifier State_12

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Other Provider Identifier Issuer_12 Other Provider Identifier_13 Other Provider Identifier Type Code_13

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Other Provider Identifier State_13 Other Provider Identifier Issuer_13 Other Provider Identifier_14

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Other Provider Identifier Type Code_14 Other Provider Identifier State_14

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Other Provider Identifier Issuer_14 Other Provider Identifier_15 Other Provider Identifier Type Code_15

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Other Provider Identifier State_15 Other Provider Identifier Issuer_15 Other Provider Identifier_16

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Other Provider Identifier Type Code_16 Other Provider Identifier State_16

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Other Provider Identifier Issuer_16 Other Provider Identifier_17 Other Provider Identifier Type Code_17

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Other Provider Identifier State_17 Other Provider Identifier Issuer_17 Other Provider Identifier_18

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Other Provider Identifier Type Code_18 Other Provider Identifier State_18

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Other Provider Identifier Issuer_18 Other Provider Identifier_19 Other Provider Identifier Type Code_19

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Other Provider Identifier State_19 Other Provider Identifier Issuer_19 Other Provider Identifier_20

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Other Provider Identifier Type Code_20 Other Provider Identifier State_20

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Other Provider Identifier Issuer_20 Other Provider Identifier_21 Other Provider Identifier Type Code_21

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Other Provider Identifier State_21 Other Provider Identifier Issuer_21 Other Provider Identifier_22

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Other Provider Identifier Type Code_22 Other Provider Identifier State_22

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Other Provider Identifier Issuer_22 Other Provider Identifier_23 Other Provider Identifier Type Code_23

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Other Provider Identifier State_23 Other Provider Identifier Issuer_23 Other Provider Identifier_24

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Other Provider Identifier Type Code_24 Other Provider Identifier State_24

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Other Provider Identifier Issuer_24 Other Provider Identifier_25 Other Provider Identifier Type Code_25

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Other Provider Identifier State_25 Other Provider Identifier Issuer_25 Other Provider Identifier_26

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Other Provider Identifier Type Code_26 Other Provider Identifier State_26

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Other Provider Identifier Issuer_26 Other Provider Identifier_27 Other Provider Identifier Type Code_27

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Other Provider Identifier State_27 Other Provider Identifier Issuer_27 Other Provider Identifier_28

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Other Provider Identifier Type Code_28 Other Provider Identifier State_28

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Other Provider Identifier Issuer_28 Other Provider Identifier_29 Other Provider Identifier Type Code_29

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Other Provider Identifier State_29 Other Provider Identifier Issuer_29 Other Provider Identifier_30

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Other Provider Identifier Type Code_30 Other Provider Identifier State_30

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Other Provider Identifier Issuer_30 Other Provider Identifier_31 Other Provider Identifier Type Code_31

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Other Provider Identifier State_31 Other Provider Identifier Issuer_31 Other Provider Identifier_32

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Other Provider Identifier Type Code_32 Other Provider Identifier State_32

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Other Provider Identifier Issuer_32 Other Provider Identifier_33 Other Provider Identifier Type Code_33

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Other Provider Identifier State_33 Other Provider Identifier Issuer_33 Other Provider Identifier_34

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Other Provider Identifier Type Code_34 Other Provider Identifier State_34

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Other Provider Identifier Issuer_34 Other Provider Identifier_35 Other Provider Identifier Type Code_35

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Other Provider Identifier State_35 Other Provider Identifier Issuer_35 Other Provider Identifier_36

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Other Provider Identifier Type Code_36 Other Provider Identifier State_36

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Other Provider Identifier Issuer_36 Other Provider Identifier_37 Other Provider Identifier Type Code_37

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Other Provider Identifier State_37 Other Provider Identifier Issuer_37 Other Provider Identifier_38

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Other Provider Identifier Type Code_38 Other Provider Identifier State_38

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Other Provider Identifier Issuer_38 Other Provider Identifier_39 Other Provider Identifier Type Code_39

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Other Provider Identifier State_39 Other Provider Identifier Issuer_39 Other Provider Identifier_40

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Other Provider Identifier Type Code_40 Other Provider Identifier State_40

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Other Provider Identifier Issuer_40 Other Provider Identifier_41 Other Provider Identifier Type Code_41

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Other Provider Identifier State_41 Other Provider Identifier Issuer_41 Other Provider Identifier_42

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Other Provider Identifier Type Code_42 Other Provider Identifier State_42

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Other Provider Identifier Issuer_42 Other Provider Identifier_43 Other Provider Identifier Type Code_43

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Other Provider Identifier State_43 Other Provider Identifier Issuer_43 Other Provider Identifier_44

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Other Provider Identifier Type Code_44 Other Provider Identifier State_44

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Other Provider Identifier Issuer_44 Other Provider Identifier_45 Other Provider Identifier Type Code_45

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Other Provider Identifier State_45 Other Provider Identifier Issuer_45 Other Provider Identifier_46

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Other Provider Identifier Type Code_46 Other Provider Identifier State_46

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Other Provider Identifier Issuer_46 Other Provider Identifier_47 Other Provider Identifier Type Code_47

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Other Provider Identifier State_47 Other Provider Identifier Issuer_47 Other Provider Identifier_48

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Other Provider Identifier Type Code_48 Other Provider Identifier State_48

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Other Provider Identifier Issuer_48 Other Provider Identifier_49 Other Provider Identifier Type Code_49

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Other Provider Identifier State_49 Other Provider Identifier Issuer_49 Other Provider Identifier_50

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Other Provider Identifier Type Code_50 Other Provider Identifier State_50

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Other Provider Identifier Issuer_50 Is Sole Proprietor Is Organization Subpart Parent Organization LBN
X
N
N

N
N
N
N
N
Y
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
X
X
N
Y
N
Y
N
X
N
N

N
N
N
N
X
N

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Parent Organization TIN Authorized Official Name Prefix Text Authorized Official Name Suffix Text

MR.

JR.

MR.

MS.

MR.

DR.

DR.

MR. JR.

DR.

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Authorized Official Credential Text Healthcare Provider Taxonomy Group_1

MD 193200000X MULTI-SPECIALTY GROUP

M.D. 193400000X MULTIPLE SINGLE SPECIALTY GROUP

MD 193400000X SINGLE SPECIALTY GROUP

M.D. 193400000X SINGLE SPECIALTY GROUP

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Healthcare Provider Taxonomy Group_2 Healthcare Provider Taxonomy Group_3

193400000X MULTIPLE SINGLE SPECIALTY GROUP

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Healthcare Provider Taxonomy Group_4 Healthcare Provider Taxonomy Group_5

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Healthcare Provider Taxonomy Group_6 Healthcare Provider Taxonomy Group_7

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Healthcare Provider Taxonomy Group_8 Healthcare Provider Taxonomy Group_9

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Healthcare Provider Taxonomy Group_10 Healthcare Provider Taxonomy Group_11

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Healthcare Provider Taxonomy Group_12 Healthcare Provider Taxonomy Group_13

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Healthcare Provider Taxonomy Group_14 Healthcare Provider Taxonomy Group_15 Certification Date

06/09/2020

03/01/2020

01/26/2021

12/24/2019

03/20/2021

10/07/2021

06/11/2021

11/19/2020

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