| NPI |
1265527725 |
|
| Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN |
|
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Organization Name Legal Business Name |
LON M. EGBERT, P.C. |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Other Organization Name |
JEROME PHYSICAL THERAPY & SPORTS MEDICINE CLINIC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Other Organization Name Type Code |
3 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
| Provider First Line Business Practice Location Address |
128 5TH AVE WEST |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
| Provider Business Practice Location Address City Name |
JEROME |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
ID |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Postal Code |
83338 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Telephone Number |
2083243090 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
2083243093 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
10/3/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
1/15/2010 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Authorized Official Last Name |
EGBERT |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
LON |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official Middle Name |
M |
The middle name of the authorized official. |
| Authorized Official Title or Position |
PRESIDENT OWNER |
The middle name of the authorized official. |
| Authorized Official Telephone Number |
2083243090 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
2255A2300X |
The 10-position telephone number of the authorized official. |
| Provider License Number 1 |
PENDING |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
ID |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
| Healthcare Provider Taxonomy Code 2 |
225100000X |
|
| Provider License Number 2 |
PT-1686 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 2 |
ID |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 2 |
Y |
|
| Other Provider Identifier 1 |
PENDING |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
ID |
|
| Is Organization Subpart |
N |
|
| Authorized Official Name Prefix Text |
MR. |
|
| Authorized Official Credential Text |
PT, ATC |
|
| Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 2 |
193200000X MULTI-SPECIALTY GROUP |
|