1952326787 NPI number — LEE CHARLES BLOEMENDAL MD

Table of content: LEE CHARLES BLOEMENDAL MD (NPI 1952326787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952326787 NPI number — LEE CHARLES BLOEMENDAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOEMENDAL
Provider First Name:
LEE
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1952326787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 961205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76161-1205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-740-8400
Provider Business Mailing Address Fax Number:
817-336-8941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 720
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-336-7305
Provider Business Practice Location Address Fax Number:
817-336-8941
Provider Enumeration Date:
07/13/2006

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: 208600000X , with the licence number:  D5919 , 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: 020054578 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 032314902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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