1275571986 NPI number — CONNIE ANN BERGLUND FNP

Table of content: CONNIE ANN BERGLUND FNP (NPI 1275571986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275571986 NPI number — CONNIE ANN BERGLUND FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGLUND
Provider First Name:
CONNIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

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:
1275571986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65808-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-269-7241
Provider Business Mailing Address Fax Number:
417-269-7567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18452 BUSINESS 13
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANSON WEST
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65737-9609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-272-8911
Provider Business Practice Location Address Fax Number:
417-272-3910
Provider Enumeration Date:
06/03/2006

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: 363LF0000X , with the licence number:  120233 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 2017000437 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 482681YYS0 . This is a "MEDICARE B PTAN FOR MOUNTAIN PEAKS URGENT CARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: P01631094 . This is a "RAILROAD WORKERS MEDICARE PTAN FOR MOUNTAIN PEAKS URGENT CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 70356785 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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