1700885605 NPI number — THERESA MARIE VAIL M.D.

Table of content: THERESA MARIE VAIL M.D. (NPI 1700885605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700885605 NPI number — THERESA MARIE VAIL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAIL
Provider First Name:
THERESA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1700885605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/24/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 S FLEISHEL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75701-2012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-595-5500
Provider Business Mailing Address Fax Number:
903-595-5506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 S FLEISHEL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-595-5500
Provider Business Practice Location Address Fax Number:
903-595-5506
Provider Enumeration Date:
07/21/2005

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: 2084P0800X , with the licence number:  L0672 , 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: 0392920-03 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 731682660 . This is a "TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8AJ103 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00039903 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 109023800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com