1124162706 NPI number — MR. BLANE AUSEN ANDERSON CCC-A

Table of content: MR. BLANE AUSEN ANDERSON CCC-A (NPI 1124162706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124162706 NPI number — MR. BLANE AUSEN ANDERSON CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BLANE
Provider Middle Name:
AUSEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CCC-A
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:
1124162706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 SHUMAN BLVD
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60563-8458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-303-5380
Provider Business Mailing Address Fax Number:
978-313-6824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 N BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ULM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56073-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-359-1932
Provider Business Practice Location Address Fax Number:
507-354-1369
Provider Enumeration Date:
02/16/2007

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: 237600000X , with the licence number:  5919 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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