1407895709 NPI number — DR. TOM RIMBERT ROARK M.D.

Table of content: DR. TOM RIMBERT ROARK M.D. (NPI 1407895709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407895709 NPI number — DR. TOM RIMBERT ROARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROARK
Provider First Name:
TOM
Provider Middle Name:
RIMBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1407895709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3807 SPICEWOOD SPRINGS RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-8965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-476-9195
Provider Business Mailing Address Fax Number:
512-476-2857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3807 SPICEWOOD SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-8965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-476-9195
Provider Business Practice Location Address Fax Number:
512-476-2857
Provider Enumeration Date:
06/05/2006

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: 207N00000X , with the licence number:  L0913 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00486U . This is a "MEDICARE GROUP BILLING #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CK3641 . This is a "RR MEDICARE GROUP ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: L0913 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0021HW . This is a "BCBS GROUP BILLING ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1245417294 . This is a "GROUP NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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