1104099050 NPI number — JOHN W. JOOSSE, MD A PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104099050 NPI number — JOHN W. JOOSSE, MD A PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN W. JOOSSE, MD A PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104099050
Entity Type Code:
Organization
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:
1411 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99701-5902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-456-5803
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-456-5803
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOOSSE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-456-5803

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  980 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD0980 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com