1316667819 NPI number — ROBERTA MUELLER CERTIFIED PEER SUPPR

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 1316667819 NPI number — ROBERTA MUELLER CERTIFIED PEER SUPPR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUELLER
Provider First Name:
ROBERTA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED PEER SUPPR
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:
1316667819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 EAST BROADWAY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BISMARK
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-222-0386
Provider Business Mailing Address Fax Number:
701-255-4891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 EAST BROADWAY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BISMARK
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-222-0386
Provider Business Practice Location Address Fax Number:
701-255-4891
Provider Enumeration Date:
09/02/2022

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: 175T00000X , with the licence number:  194 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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