| NPI |
1093920761 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code |
1 |
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 Last Name Legal Name |
COOLEY |
The last name of the provider. If the provider is an individual, this is the legal name. |
| Provider First Name |
CHARLES |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
A |
The middle name of the provider, if the provider
is an individual. |
| Provider Name Prefix Text |
DR. |
The name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
| Provider Credential Text |
D.D.S. |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider First Line Business Practice Location Address |
601 TURTLE CREEK DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
TYLER |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
TX |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
757011832 |
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 country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
9035926535 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
5/14/2007 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
6/23/2009 |
The date that a record was last updated or changed. |
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
122300000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 1 |
20146 |
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 |
TX |
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 1 |
Y |
|
| Other Provider Identifier 1 |
201047746 |
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 |
01 |
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 |
KS |
|
| Other Provider Identifier Issuer 1 |
DELTA DENTAL |
|
| Other Provider Identifier 2 |
201047746 |
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 2 |
01 |
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 2 |
CA |
|
| Other Provider Identifier Issuer 2 |
SAFEHEALTH LIFE INS. |
|
| Other Provider Identifier 3 |
201047746 |
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 3 |
01 |
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 3 |
CA |
|
| Other Provider Identifier Issuer 3 |
UNICARE |
|
| Other Provider Identifier 4 |
201047746 |
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 4 |
01 |
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 4 |
IA |
|
| Other Provider Identifier Issuer 4 |
ASSURANT |
|
| Other Provider Identifier 5 |
201047746 |
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 5 |
01 |
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 5 |
KY |
|
| Other Provider Identifier Issuer 5 |
HUMANA |
|
| Other Provider Identifier 6 |
201047746 |
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 6 |
01 |
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 6 |
GA |
|
| Other Provider Identifier Issuer 6 |
DELTA DENTAL OF GEORGIA |
|
| Other Provider Identifier 7 |
20104776 |
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 7 |
01 |
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 7 |
TX |
|
| Other Provider Identifier Issuer 7 |
HEALTHFIRST TPA |
|
| Other Provider Identifier 8 |
201047746 |
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 8 |
01 |
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 8 |
TX |
|
| Other Provider Identifier Issuer 8 |
METLIFE DENTAL |
|
| Other Provider Identifier 9 |
201047746 |
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 9 |
01 |
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 9 |
TX |
|
| Other Provider Identifier Issuer 9 |
FISERVHEALTH |
|
| Other Provider Identifier 10 |
201047746 |
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 10 |
01 |
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 10 |
MN |
|
| Other Provider Identifier Issuer 10 |
DELTA DENTAL |
|
| Other Provider Identifier 11 |
201047746 |
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 11 |
01 |
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 11 |
CA |
|
| Other Provider Identifier Issuer 11 |
BC LIFE & HEALTH DENTAL SERVICES |
|
| Other Provider Identifier 12 |
201047746 |
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 12 |
01 |
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 12 |
IL |
|
| Other Provider Identifier Issuer 12 |
LINECO |
|
| Other Provider Identifier 13 |
201047746 |
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 13 |
01 |
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 13 |
CA |
|
| Other Provider Identifier Issuer 13 |
LIBERTY DENTAL |
|
| Other Provider Identifier 14 |
201047746 |
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 14 |
01 |
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 14 |
OK |
|
| Other Provider Identifier Issuer 14 |
BLUE CROSS BLUE SHIELD OF OKLAHOMA |
|
| Other Provider Identifier 15 |
20104776 |
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 15 |
01 |
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 15 |
NC |
|
| Other Provider Identifier Issuer 15 |
PRIMARY CARE PHYSICIANS |
|
| Other Provider Identifier 16 |
201047746 |
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 16 |
01 |
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 16 |
NJ |
|
| Other Provider Identifier Issuer 16 |
DELTA DENTAL |
|
| Other Provider Identifier 17 |
201047746 |
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 17 |
01 |
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 17 |
WA |
|
| Other Provider Identifier Issuer 17 |
GUARDIAN |
|
| Other Provider Identifier 18 |
201047746 |
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 18 |
01 |
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 18 |
NC |
|
| Other Provider Identifier Issuer 18 |
COVENTRY HEALTH CARE |
|
| Other Provider Identifier 19 |
201047746 |
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 19 |
01 |
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 19 |
IA |
|
| Other Provider Identifier Issuer 19 |
DELTA DENTAL OF IOWA |
|
| Other Provider Identifier 20 |
201047746 |
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 20 |
01 |
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 20 |
AR |
|
| Other Provider Identifier Issuer 20 |
DELTA DENTAL OF ARKANSAS |
|
| Other Provider Identifier 21 |
201047746 |
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 21 |
01 |
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 21 |
CA |
|
| Other Provider Identifier Issuer 21 |
DELTA DENTAL OF CALIFORNIA |
|
| Other Provider Identifier 22 |
201047746 |
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 22 |
01 |
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 22 |
WA |
|
| Other Provider Identifier Issuer 22 |
STERLING LIFE INS. CO. |
|
| Other Provider Identifier 23 |
201047746 |
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 23 |
01 |
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 Issuer 23 |
CIGNA |
|
| Other Provider Identifier 24 |
201047746 |
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 24 |
01 |
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 24 |
MI |
|
| Other Provider Identifier Issuer 24 |
DELTA DENTAL OF MI, OH, IN |
|
| Other Provider Identifier 25 |
201047746 |
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 25 |
01 |
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 25 |
TN |
|
| Other Provider Identifier Issuer 25 |
BLUE CROSS BLUE SHIELD OF TENNESSEE |
|
| Other Provider Identifier 26 |
201047746 |
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 26 |
01 |
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 26 |
AL |
|
| Other Provider Identifier Issuer 26 |
BLUE CROSS BLUE SHIELD OF ALABAMA |
|
| Other Provider Identifier 27 |
20104776 |
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 27 |
01 |
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 27 |
IL |
|
| Other Provider Identifier Issuer 27 |
DENTAL NETWORK OF AMERICA |
|
| Other Provider Identifier 28 |
88D834 |
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 28 |
01 |
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 28 |
TX |
|
| Other Provider Identifier Issuer 28 |
BLUE CROSS BLUE SHIELD |
|
| Other Provider Identifier 29 |
201047746 |
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 29 |
01 |
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 29 |
UT |
|
| Other Provider Identifier Issuer 29 |
UNITED HEALTHCARE DENTAL |
|
| Other Provider Identifier 30 |
201047746 |
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 30 |
01 |
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 30 |
OK |
|
| Other Provider Identifier Issuer 30 |
OLD SURRETY LIFE |
|
| Other Provider Identifier 31 |
201047746 |
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 31 |
01 |
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 31 |
NY |
|
| Other Provider Identifier Issuer 31 |
DELTA DENTAL |
|
| Other Provider Identifier 32 |
201047746 |
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 32 |
01 |
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 32 |
IA |
|
| Other Provider Identifier Issuer 32 |
PRINCIPAL LIFE |
|
| Other Provider Identifier 33 |
201047746 |
|
| Other Provider Identifier Type Code 33 |
01 |
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 33 |
MA |
|
| Other Provider Identifier Issuer 33 |
SUN LIFE AND HEALTH INS. |
|
| Other Provider Identifier 34 |
201047746 |
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 34 |
01 |
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 34 |
KY |
|
| Other Provider Identifier Issuer 34 |
DELTA DENTAL OF KENTUCKY |
|
| Other Provider Identifier 35 |
20104776 |
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 35 |
01 |
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 35 |
VA |
|
| Other Provider Identifier Issuer 35 |
GENWORTH FINANCIAL |
|
| Other Provider Identifier 36 |
201047746 |
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 36 |
01 |
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 Issuer 36 |
CENTRAL STATES SOUTHEAST AND SOUTHWEST |
|
| Other Provider Identifier 37 |
201047746 |
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 37 |
01 |
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 37 |
TX |
|
| Other Provider Identifier Issuer 37 |
BLUE CROSS BLUE SHIELD FEDERAL |
|
| Other Provider Identifier 38 |
201047746 |
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 38 |
01 |
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 38 |
TX |
|
| Other Provider Identifier Issuer 38 |
UMR |
|
| Other Provider Identifier 39 |
201047746 |
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 39 |
01 |
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 39 |
KY |
|
| Other Provider Identifier Issuer 39 |
AETNA |
|
| Other Provider Identifier 40 |
201047746 |
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 40 |
01 |
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 40 |
NE |
|
| Other Provider Identifier Issuer 40 |
AMERITAS LIFE |
|
| Other Provider Identifier 41 |
201047746 |
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 41 |
01 |
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 41 |
MO |
|
| Other Provider Identifier Issuer 41 |
GEHA STATE OF TX DENTAL CHOICE |
|
| Other Provider Identifier 42 |
201047746 |
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 42 |
01 |
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 42 |
PA |
|
| Other Provider Identifier Issuer 42 |
UNITED CONCORDIA |
|
| Other Provider Identifier 43 |
201047746 |
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 43 |
01 |
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 43 |
FL |
|
| Other Provider Identifier Issuer 43 |
COMPBENEFITS |
|
| Other Provider Identifier 44 |
201047746 |
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 44 |
01 |
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 44 |
TN |
|
| Other Provider Identifier Issuer 44 |
DELTA DENTAL OF TENNESSEE |
|
| Other Provider Identifier 45 |
201047746 |
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 45 |
01 |
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 45 |
IL |
|
| Other Provider Identifier Issuer 45 |
BLUE CROSS BLUE SHIELD OF ILLINOIS |
|
| Other Provider Identifier 46 |
20104776 |
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 46 |
01 |
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 46 |
TX |
|
| Other Provider Identifier Issuer 46 |
WEB TPA |
|
| Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |