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jgautsch/small_npi.csv

Created August 22, 2014 02:32
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small NPI sample, part of the greater NPI dataset
Raw
small_npi.csv
NPI Entity Type Code Replacement NPI Employer Identification Number (EIN) Provider Organization Name (Legal Business Name) Provider Last Name (Legal Name) Provider First Name Provider Middle Name Provider Name Prefix Text Provider Name Suffix Text Provider Credential Text 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 Provider First Line Business Mailing Address Provider Second Line Business Mailing Address Provider Business Mailing Address City Name Provider Business Mailing Address State Name Provider Business Mailing Address Postal Code Provider Business Mailing Address Country Code (If outside U.S.) Provider Business Mailing Address Telephone Number Provider Business Mailing Address Fax Number Provider First Line Business Practice Location Address Provider Second Line Business Practice Location Address Provider Business Practice Location Address City Name Provider Business Practice Location Address State Name Provider Business Practice Location Address Postal Code Provider Business Practice Location Address Country Code (If outside U.S.) Provider Business Practice Location Address Telephone Number Provider Business Practice Location Address Fax Number Provider Enumeration Date Last Update Date NPI Deactivation Reason Code NPI Deactivation Date NPI Reactivation Date Provider Gender Code Authorized Official Last Name Authorized Official First Name Authorized Official Middle Name Authorized Official Title or Position Authorized Official Telephone Number Healthcare Provider Taxonomy Code_1 Provider License Number_1 Provider License Number State Code_1 Healthcare Provider Primary Taxonomy Switch_1 Healthcare Provider Taxonomy Code_2 Provider License Number_2 Provider License Number State Code_2 Healthcare Provider Primary Taxonomy Switch_2 Healthcare Provider Taxonomy Code_3 Provider License Number_3 Provider License Number State Code_3 Healthcare Provider Primary Taxonomy Switch_3 Healthcare Provider Taxonomy Code_4 Provider License Number_4 Provider License Number State Code_4 Healthcare Provider Primary Taxonomy Switch_4 Healthcare Provider Taxonomy Code_5 Provider License Number_5 Provider License Number State Code_5 Healthcare Provider Primary Taxonomy Switch_5 Healthcare Provider Taxonomy Code_6 Provider License Number_6 Provider License Number State Code_6 Healthcare Provider Primary Taxonomy Switch_6 Healthcare Provider Taxonomy Code_7 Provider License Number_7 Provider License Number State Code_7 Healthcare Provider Primary Taxonomy Switch_7 Healthcare Provider Taxonomy Code_8 Provider License Number_8 Provider License Number State Code_8 Healthcare Provider Primary Taxonomy Switch_8 Healthcare Provider Taxonomy Code_9 Provider License Number_9 Provider License Number State Code_9 Healthcare Provider Primary Taxonomy Switch_9 Healthcare Provider Taxonomy Code_10 Provider License Number_10 Provider License Number State Code_10 Healthcare Provider Primary Taxonomy Switch_10 Healthcare Provider Taxonomy Code_11 Provider License Number_11 Provider License Number State Code_11 Healthcare Provider Primary Taxonomy Switch_11 Healthcare Provider Taxonomy Code_12 Provider License Number_12 Provider License Number State Code_12 Healthcare Provider Primary Taxonomy Switch_12 Healthcare Provider Taxonomy Code_13 Provider License Number_13 Provider License Number State Code_13 Healthcare Provider Primary Taxonomy Switch_13 Healthcare Provider Taxonomy Code_14 Provider License Number_14 Provider License Number State Code_14 Healthcare Provider Primary Taxonomy Switch_14 Healthcare Provider Taxonomy Code_15 Provider License Number_15 Provider License Number State Code_15 Healthcare Provider Primary Taxonomy Switch_15 Other Provider Identifier_1 Other Provider Identifier Type Code_1 Other Provider Identifier State_1 Other Provider Identifier Issuer_1 Other Provider Identifier_2 Other Provider Identifier Type Code_2 Other Provider Identifier State_2 Other Provider Identifier Issuer_2 Other Provider Identifier_3 Other Provider Identifier Type Code_3 Other Provider Identifier State_3 Other Provider Identifier Issuer_3 Other Provider Identifier_4 Other Provider Identifier Type Code_4 Other Provider Identifier State_4 Other Provider Identifier Issuer_4 Other Provider Identifier_5 Other Provider Identifier Type Code_5 Other Provider Identifier State_5 Other Provider Identifier Issuer_5 Other Provider Identifier_6 Other Provider Identifier Type Code_6 Other Provider Identifier State_6 Other Provider Identifier Issuer_6 Other Provider Identifier_7 Other Provider Identifier Type Code_7 Other Provider Identifier State_7 Other Provider Identifier Issuer_7 Other Provider Identifier_8 Other Provider Identifier Type Code_8 Other Provider Identifier State_8 Other Provider Identifier Issuer_8 Other Provider Identifier_9 Other Provider Identifier Type Code_9 Other Provider Identifier State_9 Other Provider Identifier Issuer_9 Other Provider Identifier_10 Other Provider Identifier Type Code_10 Other Provider Identifier State_10 Other Provider Identifier Issuer_10 Other Provider Identifier_11 Other Provider Identifier Type Code_11 Other Provider Identifier State_11 Other Provider Identifier Issuer_11 Other Provider Identifier_12 Other Provider Identifier Type Code_12 Other Provider Identifier State_12 Other Provider Identifier Issuer_12 Other Provider Identifier_13 Other Provider Identifier Type Code_13 Other Provider Identifier State_13 Other Provider Identifier Issuer_13 Other Provider Identifier_14 Other Provider Identifier Type Code_14 Other Provider Identifier State_14 Other Provider Identifier Issuer_14 Other Provider Identifier_15 Other Provider Identifier Type Code_15 Other Provider Identifier State_15 Other Provider Identifier Issuer_15 Other Provider Identifier_16 Other Provider Identifier Type Code_16 Other Provider Identifier State_16 Other Provider Identifier Issuer_16 Other Provider Identifier_17 Other Provider Identifier Type Code_17 Other Provider Identifier State_17 Other Provider Identifier Issuer_17 Other Provider Identifier_18 Other Provider Identifier Type Code_18 Other Provider Identifier State_18 Other Provider Identifier Issuer_18 Other Provider Identifier_19 Other Provider Identifier Type Code_19 Other Provider Identifier State_19 Other Provider Identifier Issuer_19 Other Provider Identifier_20 Other Provider Identifier Type Code_20 Other Provider Identifier State_20 Other Provider Identifier Issuer_20 Other Provider Identifier_21 Other Provider Identifier Type Code_21 Other Provider Identifier State_21 Other Provider Identifier Issuer_21 Other Provider Identifier_22 Other Provider Identifier Type Code_22 Other Provider Identifier State_22 Other Provider Identifier Issuer_22 Other Provider Identifier_23 Other Provider Identifier Type Code_23 Other Provider Identifier State_23 Other Provider Identifier Issuer_23 Other Provider Identifier_24 Other Provider Identifier Type Code_24 Other Provider Identifier State_24 Other Provider Identifier Issuer_24 Other Provider Identifier_25 Other Provider Identifier Type Code_25 Other Provider Identifier State_25 Other Provider Identifier Issuer_25 Other Provider Identifier_26 Other Provider Identifier Type Code_26 Other Provider Identifier State_26 Other Provider Identifier Issuer_26 Other Provider Identifier_27 Other Provider Identifier Type Code_27 Other Provider Identifier State_27 Other Provider Identifier Issuer_27 Other Provider Identifier_28 Other Provider Identifier Type Code_28 Other Provider Identifier State_28 Other Provider Identifier Issuer_28 Other Provider Identifier_29 Other Provider Identifier Type Code_29 Other Provider Identifier State_29 Other Provider Identifier Issuer_29 Other Provider Identifier_30 Other Provider Identifier Type Code_30 Other Provider Identifier State_30 Other Provider Identifier Issuer_30 Other Provider Identifier_31 Other Provider Identifier Type Code_31 Other Provider Identifier State_31 Other Provider Identifier Issuer_31 Other Provider Identifier_32 Other Provider Identifier Type Code_32 Other Provider Identifier State_32 Other Provider Identifier Issuer_32 Other Provider Identifier_33 Other Provider Identifier Type Code_33 Other Provider Identifier State_33 Other Provider Identifier Issuer_33 Other Provider Identifier_34 Other Provider Identifier Type Code_34 Other Provider Identifier State_34 Other Provider Identifier Issuer_34 Other Provider Identifier_35 Other Provider Identifier Type Code_35 Other Provider Identifier State_35 Other Provider Identifier Issuer_35 Other Provider Identifier_36 Other Provider Identifier Type Code_36 Other Provider Identifier State_36 Other Provider Identifier Issuer_36 Other Provider Identifier_37 Other Provider Identifier Type Code_37 Other Provider Identifier State_37 Other Provider Identifier Issuer_37 Other Provider Identifier_38 Other Provider Identifier Type Code_38 Other Provider Identifier State_38 Other Provider Identifier Issuer_38 Other Provider Identifier_39 Other Provider Identifier Type Code_39 Other Provider Identifier State_39 Other Provider Identifier Issuer_39 Other Provider Identifier_40 Other Provider Identifier Type Code_40 Other Provider Identifier State_40 Other Provider Identifier Issuer_40 Other Provider Identifier_41 Other Provider Identifier Type Code_41 Other Provider Identifier State_41 Other Provider Identifier Issuer_41 Other Provider Identifier_42 Other Provider Identifier Type Code_42 Other Provider Identifier State_42 Other Provider Identifier Issuer_42 Other Provider Identifier_43 Other Provider Identifier Type Code_43 Other Provider Identifier State_43 Other Provider Identifier Issuer_43 Other Provider Identifier_44 Other Provider Identifier Type Code_44 Other Provider Identifier State_44 Other Provider Identifier Issuer_44 Other Provider Identifier_45 Other Provider Identifier Type Code_45 Other Provider Identifier State_45 Other Provider Identifier Issuer_45 Other Provider Identifier_46 Other Provider Identifier Type Code_46 Other Provider Identifier State_46 Other Provider Identifier Issuer_46 Other Provider Identifier_47 Other Provider Identifier Type Code_47 Other Provider Identifier State_47 Other Provider Identifier Issuer_47 Other Provider Identifier_48 Other Provider Identifier Type Code_48 Other Provider Identifier State_48 Other Provider Identifier Issuer_48 Other Provider Identifier_49 Other Provider Identifier Type Code_49 Other Provider Identifier State_49 Other Provider Identifier Issuer_49 Other Provider Identifier_50 Other Provider Identifier Type Code_50 Other Provider Identifier State_50 Other Provider Identifier Issuer_50 Is Sole Proprietor Is Organization Subpart Parent Organization LBN Parent Organization TIN Authorized Official Name Prefix Text Authorized Official Name Suffix Text Authorized Official Credential Text Healthcare Provider Taxonomy Group_1 Healthcare Provider Taxonomy Group_2 Healthcare Provider Taxonomy Group_3 Healthcare Provider Taxonomy Group_4 Healthcare Provider Taxonomy Group_5 Healthcare Provider Taxonomy Group_6 Healthcare Provider Taxonomy Group_7 Healthcare Provider Taxonomy Group_8 Healthcare Provider Taxonomy Group_9 Healthcare Provider Taxonomy Group_10 Healthcare Provider Taxonomy Group_11 Healthcare Provider Taxonomy Group_12 Healthcare Provider Taxonomy Group_13 Healthcare Provider Taxonomy Group_14 Healthcare Provider Taxonomy Group_15
1679576722 1 WIEBE DAVID A M.D. PO BOX 2168 KEARNEY NE 688482168 US 3088652512 3088652506 3500 CENTRAL AVE KEARNEY NE 688472944 US 3088652512 3088652506 05/23/2005 07/08/2007 M 207X00000X 12637 NE Y 46969 01 KS BCBS 645540 01 KS FIRSTGUARD B67599 02 1553 01 NE BCBS 046969WI 04 KS 93420WI 04 NE X
1588667638 1 PILCHER WILLIAM C DR. MD 1824 KING STREET SUITE 300 JACKSONVILLE FL 322044736 US 9043881820 9043881827 1824 KING STREET SUITE 300 JACKSONVILLE FL 322044736 US 9043881820 9043881827 05/23/2005 05/29/2014 M 207RC0000X 032024 GA N 207RC0000X ME68414 FL Y 208143 01 FL AVMED C73899 02 FL 27888Z 04 FL 06BDGPK 04 GA 00532485C 05 GA 251286600 05 FL 00706626A 05 GA 0897705 01 FL AETNA 27888 01 FL BCBS 510265 01 GA BCBS 110123591 04 FL RAILROAD MCARE N
1497758544 2 <UNAVAIL> CUMBERLAND COUNTY HOSPITAL SYSTEM, INC CAPE FEAR VALLEY HOME HEALTH AND HOSPICE 3 3418 VILLAGE DR FAYETTEVILLE NC 283044552 US 9106096740 3418 VILLAGE DR FAYETTEVILLE NC 283044552 US 9106096740 05/23/2005 09/26/2011 NAGOWSKI MICHAEL CEO 9106096700 251G00000X HC0283 NC Y 3401562 05 NC 341562 04 NC PROVIDER NUMBER N MR.
1306849450 1 SMITSON HAROLD LEROY DR. II M.D. 810 LUCAS DR ATHENS TX 757513446 US 9036756778 9036752333 810 LUCAS DR ATHENS TX 757513446 US 9036756778 9036752333 05/23/2005 01/03/2008 M 2085R0202X E5444 TX Y 83R321 08 TX B26530 02 TX N
1215930367 1 GRESSOT LAURENT DR. M.D. PO BOX 4356 DEPT 664 HOUSTON TX 772104356 US 2814405006 2814406149 17323 RED OAK DR HOUSTON TX 770901243 US 2814405006 2814406149 05/23/2005 08/06/2013 M 174400000X H6257 TX N 207RH0003X H6257 TX Y E43866 02 TX 89G024 08 TX 830005153 08 TX 1215930367 08 TX 0533800001 07 TX N
1023011178 2 <UNAVAIL> NAPA VALLEY HOSPICE & ADULT DAY SERVICES 414 S JEFFERSON ST NAPA CA 945594515 US 7072589080 7072582476 414 S JEFFERSON ST NAPA CA 945594515 US 7072589080 7072582476 05/23/2005 10/17/2011 VOLKERTS KEITH REGIS DIRECTOR OF FINANCE 7072589080 251G00000X 100000741 CA Y HPC01537G 05 CA 051537 04 CA HOSPICE MEDICARE NO N MR.
1932102084 1 ADUSUMILLI RAVI K MD 2940 N MCCORD RD TOLEDO OH 436151753 US 4198423000 4198423048 2940 N MCCORD RD TOLEDO OH 436151753 US 4198423000 4198423048 05/23/2005 04/23/2012 M 207RC0000X 4301081344 MI N 207RC0000X 35069014 OH Y 060060579 08 OH 4042628 08 OH MI1635021 08 MI P00751116 01 RAILROAD MEDICARE 0178623 05 OH 0792002 08 OH MI1635026 08 MI AD4257781 08 OH E21287 02 4042622 08 OH 4042627 08 OH 4042629 08 OH 0792003 08 OH 4042624 08 OH N
1841293990 1 WORTSMAN SUSAN MA-CCC 68 ROCKLEDGE RD APT 1C HARTSDALE NY 105303455 US 2124814464 425 E 25TH ST NEW YORK NY 100102547 US 2124814464 05/23/2005 07/08/2007 F 231H00000X 000396-1 NY Y M72081 04 NY PROVIDER NUMBER N
1750384806 1 BISBEE ROBERT DR. MD 5219 CITY BANK PKWY STE 35 LUBBOCK TX 794073545 US 8067852045 8067222908 113 WALNUT ST IDALOU TX 793294003 US 8068922537 8068922726 05/23/2005 01/13/2012 M 207R00000X J8461 TX Y G22052 02 TX N
1669475711 1 SUNG BIN SHENG M. D. 4780 SWEETWATER BLVD STE 100 SUGAR LAND TX 774793163 US 2815657337 2815656183 4780 SWEETWATER BLVD STE 100 SUGAR LAND TX 774793163 US 2815657337 2815656183 05/23/2005 07/08/2007 F 208000000X J1405 TX Y F65072 02 1270548 05 TX Y
1578566626 1 KUIPERS WARREN D. MD 8620 N 22ND AVE 200 PHOENIX AZ 850214251 US 6026746506 6026746512 4524 N MARYVALE PKWY STE 120 PHOENIX AZ 85031 US 6238484460 6238484485 05/23/2005 08/20/2008 M 207Q00000X 23525 AZ Y Z74867 08 AZ D57473 02 325052 05 AZ N
1487657532 1 HUEBERT ALLISON L DR. M.D. PO BOX 1330 NORMAN OK 730701330 US 4053076630 4053076660 3400 W TECUMSEH RD SUITE 205 NORMAN OK 730721810 US 4057932229 4059123579 05/23/2005 06/25/2013 F 207V00000X 21240 OK Y 38436 01 OK BNDD BH6720381 01 OK DEA N
1396748448 1 YOUNGMAYKA CYNTHIA P.A. 8100 OSWEGO RD SUITE 220 LIVERPOOL NY 130901654 US 3156526551 3156529698 8100 OSWEGO RD SUITE 220 LIVERPOOL NY 130901654 US 3156526551 3156529698 05/23/2005 09/12/2011 F 363A00000X 0040721 NY Y R88663 02 NY 01270915 05 NY N
1205839354 1 DIFILIPPO EMIL A DR. M.D. 9323 PHOENIX VILLAGE PKWY O FALLON MO 633664281 US 6365615030 6365615033 9323 PHOENIX VILLAGE PKWY O FALLON MO 633664281 US 6365615030 6365615033 05/23/2005 03/01/2012 M 207X00000X 30530 MO Y 4432V6097 01 HEALTHCARE USA 990000528 04 MO 6034V3458 01 GHP/ADVANTRA 119066 01 HEALTHLINK 21646 01 MO BLUE CROSS BLUE SHIELD 4061313 01 AETNA 45619 01 CMR A10875 01 MHP/PREMIER PLUS A10875 02 351240001 01 CIGNA DMERC 10015552 04 MO RAILROAD 900093 01 UHC 9042 01 EXCLUSIVE CHOICE SP10135 01 CIGNA N
1114920261 1 THACKER RICHARD RANDALL DR. D.O. 2626 CARE DR STE 200 TALLAHASSEE FL 323084489 US 8508788235 8502192395 2626 CARE DR STE 200 TALLAHASSEE FL 323084489 US 8508788235 8502192395 05/23/2005 05/19/2009 M 207R00000X MEOS6976 FL Y P00625814 01 FL MEDICARE RAILROAD G12328 02 FL 57088Y 04 FL 058464900 01 FL MEDICAID GROUP 57188 01 FL INDIVIDUAL PROVIDER BCBS 99039 01 FL GROUP BCBS ID NUMBER 37822101 05 FL 1114920261 05 GA N
1023011079 2 <UNAVAIL> ADVANTAGE HOME HEALTH CARE, INC. 23950 S NORTHERN ILLINOIS DR CHANNAHON IL 604105184 US 8154671905 8154676392 23950 S NORTHERN ILLINOIS DR CHANNAHON IL 604105184 US 8154671905 8154676392 05/23/2005 12/20/2011 WELTER SHARON A DIRECTOR 8154671905 251E00000X 1008614 IL Y 147644 04 IL N MRS.
1932102985 1 ROTHSTEIN MARK TERRY DR. M.D. 75 HOSPITAL DR SUITE 140 ATHENS OH 457012857 US 7405924491 7405924844 75 HOSPITAL DR SUITE 140 ATHENS OH 457012857 US 7405924491 7405924844 05/23/2005 12/11/2013 M 207Q00000X MD011535 HI N 207Q00000X 35-037876 OH Y RO0408502 04 A75189 02 0259134 05 OH N
1841293891 1 GIBBS ELMER RICKEY DR. M.D. 1645 SOUTH MAIN ST. STE. 101 CROSSVILLE TN 38555 US 9314847531 9314569515 1645 SOUTH MAIN ST. STE. 101 CROSSVILLE TN 38555 US 9314847531 9314569515 05/23/2005 06/16/2010 M 208G00000X 35733 TN N 208600000X 35733 TN Y 27-1779467 01 TAX ID H68773 02 TN 3382060 05 TN 3877794 08 TN 4252798 01 TN BC/BS OF TN 4042486 01 TN TENNCARE SELECT NUMBER 3382060 04 TN Y
1750384707 1 MARKMAN ALAN WILLIAM DR. M.D. 3800 PARK NICOLLET BLVD CREDENTIALING ST LOUIS PARK MN 554162527 US 8100 NORTHLAND DR MINNEAPOLIS MN 554314800 US 9528318742 9528311626 05/23/2005 03/05/2012 M 174400000X 25873 MN Y 200002234 04 MN A94061 02 MN N
1669475612 1 TROTCHIE DEBBIE C APN MUDDER DEBBIE C 1 PO BOX 1737 LAS VEGAS NV 891251737 US 7026716845 7026716883 3196 S MARYLAND PKWY STE 303 LAS VEGAS NV 891092305 US 7023832919 7023832886 05/23/2005 11/12/2007 F 363LW0102X APN00355 NV Y N
1578566527 1 DYSART STANLEY H M.D. 300 TOWER RD NE STE 200 MARIETTA GA 300609403 US 7704275717 7704296503 300 TOWER RD NE STE 200 MARIETTA GA 300609403 US 7704275717 7704296503 05/23/2005 12/05/2013 M 207X00000X 031591 GA Y 20BBCZL 04 GA E80424 02 GA N
1487657433 2 <UNAVAIL> PEKIN MRI, LLC 1894 GEORGETOWN RD HUDSON OH 442364058 US 3306533968 3306561660 1300 PARK AVE PEKIN IL 615545038 US 3093472143 3093472416 05/23/2005 04/20/2008 COYNE V. RENAE DIRECTOR OF BILLING 3306533968 293D00000X Y =========001 05 IL 200561 04 IL MS.
1396748349 1 GRUNERT GEORGE M DR. M.D. PO BOX 4048 HOUSTON TX 772104048 US 7135127000 7135127082 7900 FANNIN ST SUITE 4000 HOUSTON TX 770542934 US 7135127000 7135127082 05/23/2005 04/08/2014 M 207VE0102X E0945 TX Y 84325J 04 TX BRAZORIA B23159 02 TX 84282J 04 TX HARRIS COUNTY 84380J 04 TX FT.BEND/MONT 83047G 01 TX BLUE CROSS & BLUE SHIELD N
1205839255 1 GOLDBERG STEVEN M DR. M.D. 1010 NORTHERN BLVD STE 110 GREAT NECK NY 110215306 US 5163902430 5164827955 1010 NORTHERN BLVD STE 110 GREAT NECK NY 110215306 US 5163902430 5164827955 05/23/2005 04/04/2011 M 207RC0000X 144482 NY Y C06133 02 NY SG016D6410 04 NY MEDICARE PROVIDER N
1114920162 1 DUBOSE JON DR. MD 111 HOSPITAL DR TARBORO NC 278862011 US 2526417700 2526417313 111 HOSPITAL DR TARBORO NC 278862011 US 2526417700 2526417313 05/23/2005 02/14/2014 M 208000000X 200101440 NC N 207R00000X 200101440 NC Y H82304 02 NC 2014449 04 NC 891330U 05 NC N
1922001973 1 ANDERSON-KRULL TERESA MARY MS. MSW LICSW 216 E MAIN ST ALBERT LEA MN 560072919 US 5073770107 5073771194 216 E MAIN ST ALBERT LEA MN 560072919 US 5073770107 5073771194 05/23/2005 07/08/2007 F 1041C0700X 2581 MN Y HP40008 01 MN HEALTH PARTNERS 025801 01 MN VMC BEHAVIORAL HEALTHCARE 131L4AN 01 MN BLUE SHIELD 103903 01 MN UCARE X
1831192889 1 COE CRAIG L. MD 210 WESTSIDE DR DOTHAN AL 363031928 US 3347935074 3347936460 210 WESTSIDE DR DOTHAN AL 363031928 US 3347935074 3347936460 05/23/2005 07/09/2007 M 207R00000X 9845 AL Y C73181 02 AL X
1740283795 2 <UNAVAIL> EASTERN STAR MASONIC HOME 715 W 3RD ST BOONE IA 500363930 US 5154325274 5154325276 715 W 3RD ST BOONE IA 500363930 US 5154325274 5154325276 05/23/2005 03/04/2008 BOCK DENNIS A. ADMINISTRATOR 5154325274 314000000X N-0268 IA N 311Z00000X R-268 IA N 313M00000X N-0268 IA Y 0801076 05 IA 0890210 05 IA 16-5468 08 IA 165468 06 IA N MR.
1659374601 1 OBERDICK WENDY TIPTON MD TIPTON WENDY NANETTE DR. MD 1 PO BOX 9 KINGSPORT TN 376620009 US 4238572066 4238572070 105 W STONE DR STE 1F KINGSPORT TN 376603365 US 4232302420 4232302422 05/23/2005 10/20/2011 05/23/2005 05/24/2005 F 207Q00000X 200133 LA N 207Q00000X MD200133 LA N 207Q00000X MD46567 TN Y 103I083863 08 TN 4J6606629 08 LA 4J660 08 LA 1623512 05 LA 1520114 05 TN G65207 02 Y
1568465516 1 SALENGER RAWN M.D. 257 LAFAYETTE AVE SUITE 330 SUFFERN NY 109014830 US 8453688800 8453685608 257 LAFAYETTE AVE SUITE 330 SUFFERN NY 109014830 US 8453688800 8453685608 05/23/2005 02/28/2013 M 208G00000X 212244 MA N 208G00000X 232808 NY Y N
1477556421 1 ROTH STEVEN S. DR. O.D. 1107 MANTUA PIKE STE 722 MANTUA NJ 080511606 US 8564649000 8564641577 1107 MANTUA PIKE STE 722 MANTUA NJ 080511606 US 8564649000 8564641577 05/23/2005 07/08/2007 M 152W00000X 27TO00030000 NJ N 152W00000X 27OA00378500 NJ Y T77698 02 0024503 04 2254417 05 NJ Y
1255334207 1 SOUCIER RICHARD MD 1000 ASYLUM AVE STE 2109A HARTFORD CT 061051719 US 8607146581 8607148311 114 WOODLAND ST HARTFORD CT 061051208 US 8607144820 8607148001 05/23/2005 03/17/2014 M 207RC0000X 033435 CT Y G37130 02 CT 001334359 05 CT 060001181 04 CT N
1164425112 1 ISETTS BRIAN JOHN DR. B.C.P.S., PH.D. 3510 WILD TURKEY RD RED WING MN 550661765 US 6513858353 308 HARVARD ST SE RM 7-175 MINNEAPOLIS MN 554550353 US 6126242140 6126259931 05/23/2005 07/08/2007 M 1835P1200X 113541-1 MN Y X
1073516027 1 CHANG JOHN CHU-HONG DR. M.D. 169 N MIDDLETOWN RD PEARL RIVER NY 109652029 US 8457355666 8457355673 169 N MIDDLETOWN RD PEARL RIVER NY 109652029 US 8457355666 8457355673 05/23/2005 10/06/2009 M 174400000X 225687-1 NY Y 02362274 05 NY P00014839 08 NY WEX951 08 NY 429B41 04 NY P00014839 01 NY PALMETTO GBA RAILROAD MEDICARE H76950 02 NY 132998987 01 NY TAX ID N
1982607933 2 <UNAVAIL> ADR LLC PO BOX 808 CUMBERLAND MD 215010808 US 3017241646 3017247429 952 SETON DR CUMBERLAND MD 215021950 US 3017773522 3017771902 05/23/2005 08/16/2010 KIM JONG K PRESIDENT 3017241646 174400000X Y 403741300 05 MD 762M 04 MD DA5555 01 RAILROAD MEDICARE 0201927000 05 WV 001586989 01 WV MT ST BS 216A 01 MD MD BLUE SHIELD 762M 08 MD J249 01 MD MD BLUE SHIELD DA5555 08 N DR. MD 193200000X MULTI-SPECIALTY GROUP
1891798849 1 PULIZZI JOHN S JR. M.D. 3450 N BEAUREGARD ST STE 1 ALEXANDRIA VA 223021200 US 7038207000 7039310059 3450 N BEAUREGARD ST STE 1 ALEXANDRIA VA 223021200 US 7038207000 7039310059 05/23/2005 07/09/2007 M 208D00000X 0101016313 VA Y 4088438 01 VA AETNA ID 035935 01 VA ANTHEM ID 246820 01 VA MAMSI 0002 01 VA B/C INDIVIDUAL # 408722 04 VA GROUP ID 2156 01 VA B/C GROUP # D18029 02 VA N
1700889755 2 <UNAVAIL> AZAR/FILIPOV MD PA 31519 WINTERPLACE PKWY STE 1 SALISBURY MD 218041884 US 4105462500 4105465005 31519 WINTERPLACE PKWY STE 1 SALISBURY MD 218041884 US 4105462500 4105465005 05/23/2005 03/30/2011 AZAR ALEX PRESIDENT 4105462500 152W00000X N 207W00000X Y CL6244 08 MD G02090 08 DE 174L 08 MD 063341100 05 MD DD9992 08 DE N DR. M.D. 193400000X MULTIPLE SINGLE SPECIALTY GROUP 193400000X MULTIPLE SINGLE SPECIALTY GROUP
1619970662 1 FRIEDMAN LISA AMY MRS. RN, MSN, CPNP 333 N SANTA ROSA SAN ANTONIO TX 782073108 US 2107042190 333 N SANTA ROSA SAN ANTONIO TX 782073108 US 2107042190 05/23/2005 07/15/2007 F 363LP0200X 662780 TX Y N
1427051473 2 <UNAVAIL> OAKVIEW MEDICAL CARE FACILITY 1001 DIANA ST LUDINGTON MI 494311908 US 2318455185 2318457957 1001 DIANA ST LUDINGTON MI 494311908 US 2318455185 2318457957 05/23/2005 10/26/2011 WHITE NORMAN J DIRECTOR OF FINANCIAL SERVICES 2318455185 314000000X 2033624 MI N 314000000X 538510 MI Y 235072 04 MI 2085286 05 MI N MR. JR.
1336142389 2 <UNAVAIL> ADIRONDACK MEDICAL HEALTH CARE ASSOCIATES PLLC PO BOX 2004 EAST SYRACUSE NY 130574504 US 3153625285 3154452936 1656 CHAMPLIN AVE NEW HARTFORD NY 134131068 US 3156246222 3156246308 05/23/2005 07/08/2007 FINLEY ANDREW L PRESIDENT 3156246222 207P00000X NA NY Y MD 193400000X SINGLE SPECIALTY GROUP
1245233295 1 POTTS JILL K DR. M.D. 335 PARRISH ST CANANDAIGUA NY 144241728 US 5853932845 5853969275 335 PARRISH ST CANANDAIGUA NY 144241728 US 5853932845 5853969275 05/23/2005 07/08/2007 F 207R00000X 210694 NY Y MDC741 01 NY PREFERRED CARE 6996 01 NY BLUE SHIELD 01859558 05 NY G81076 02 NY BB2324 04 NY X
1962405910 2 <UNAVAIL> ALABAMA CARDIOVASCULAR GROUP, P.C. 2700 10TH AVE S STE 305 BIRMINGHAM AL 352051248 US 2059390139 2059394997 2700 10TH AVE S STE 305 BIRMINGHAM AL 352051248 US 2059390139 2059394997 05/23/2005 07/09/2009 ARCINIEGAS JOAQUIN G. PRESIDENT 2059390139 174400000X Y J192 04 AL BESSEMER SUITE 403 J193 04 AL BESSEMER SUITE X01 J196 01 AL MEDICARE MCE J199 04 AL ST. VINCENT'S LOCATION N DR. M.D. 193400000X SINGLE SPECIALTY GROUP
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