1760580013 NPI number — MARY K ROSS DPT

Table of content: MARY K ROSS DPT (NPI 1760580013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760580013 NPI number — MARY K ROSS DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLAKEMAN
Provider Other First Name:
MARY
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1760580013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 S 1ST AVE
Provider Second Line Business Mailing Address:
PO BOX 435
Provider Business Mailing Address City Name:
BROKEN BOW
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68822-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-872-5111
Provider Business Mailing Address Fax Number:
308-872-5115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 S 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN BOW
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68822-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-872-5111
Provider Business Practice Location Address Fax Number:
308-872-5115
Provider Enumeration Date:
09/20/2006

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: 225100000X , with the licence number:  1511 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39519 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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