BLEAKLY NICOLE TERESA MD Individual Gender Enumeration Date Last Update Date Deactivation Reason Code Deactivation Date Reactivation Date Employer Identification Number EIN Female 06122008 09112014 SECTION 2 CONTACT INFORMATION Business Mailing Add ID: 38892
Download Pdf The PPT/PDF document "HIPAASpace NPI Form Source NPI Lookup NA..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
(NPPES) to assign these unique identifiers. NPI 1881854990 10-position all-numeric identification numberassigned by the NPS to uniquely identify a healthcare provider. Entity Type Individual Code describing the type of health care provider thatis being assigned an NPI. Codes are:&#xul00;&#xli00; ()&#x/li0;furnishes health care;&#xli00; ()individual human being that furnishes health care(for example, hospital, SNF, hospital subunit,&#x/li0;pharmacy, or HMO).&#x/ul0; Is Sole Proprietor N Indicate whether provider is a sole proprietor.&#xul00;&#xli00; ()of a business that is not incorporated; thatunincorporated business is a sole&#x/li0;proprietorship.&#xli00; owns all of the assets of the business and is solely&#x/li0;liable for all of the debts of the business.&#xli00; proprietorship and a sole proprietor; they are legally&#x/li0;a single entity: an individual.&#xli00; is an Entity type 1 (Individual) and is eligible for onlyone NPI (the sole proprietorship business is not&#x/li0;eligible for its own NPI).&#xli00; be a subpart and cannot have subparts. (See NPI&#x/li0;Final Rule for information about subparts.)&#xli00; &#x/li0;employees.&#xli00; proprietorship in order to protect the soleproprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's&#x/li0;EIN.&#xli00; sole proprietorships (for example, group practices,&#x/li0;pharmacies, home health agencies).&#x/ul0; Provider Last Name(Legal Name) KORTZ The last name of the provider (if an individual). If theprovider is an individual, this is the legal name. Thisname must match the name on file with the SocialSecurity Administration (SSA). In addition, the dateof birth must match that on file with SSA. (First andlast names are required for initial applications.) TheFirst, Middle, Last and Credential(s) fields allow thefollowing special characters: ampersand,apostrophe, colon, comma, forward slash, hyphen,left and right parentheses, period, pound sign,quotation mark, and semi-colon. A field cannotcontain all special characters. Provider First Name TERESA The first name of the provider, if the provider is anindividual. Provider Middle Name BLEAKLY The middle name of the provider, if the provider isan individual. Provider Name PrefixText DR. The name prefix or salutation of the provider if theprovider is an individual; for example, Mr., Mrs., orCorporal. Provider CredentialText M.D., MS The abbreviations for professional degrees orcredentials used or held by the provider, if theprovider is an individual. Examples are MD, DDS,CSW, CNA, AA, NP, RNA, or PSY. These credentialdesignations will not be verified by NPS. Provider Other LastName BLEAKLY Other last name by which the provider beingidentified is or has been known (if an individual) Provider Other FirstName NICOLE Other first name by which the provider beingidentified is or has been known (if an individual).This may be the same as the ''Provider first name'' ifthe provider is or has been known by a different lastname only. Provider Other MiddleName TERESA Other middle name by which the provider beingidentified is or has been known (if an individual).This may be the same as the ''Provider middlename'' if the provider is or has been known by adifferent last name only. Provider Other LastName Type Code 1 Code identifying the type of other name. Codes are:1 = former name; 2 = professional name; 5 = other. Provider First LineBusiness MailingAddress UCSF DEPARTMENTOF PEDIATRICS,MAILCODE 0106 The first line mailing address of the provider beingidentified. This data element may contain the sameinformation as ''Provider first line location address''. Provider Second LineBusiness MailingAddress 550 16TH STREET, 5THFLOOR The second line mailing address of the providerbeing identified. This data element may contain thesame information as ''Provider second line locationaddress''. Provider BusinessMailing Address CityName SAN FRANCISCO The City name in the mailing address of the providerbeing identified. This data element may contain thesame information as ''Provider location address Cityname''. Provider BusinessMailing Address StateName CA The State or Province name in the mailing addressof the provider being identified. This data elementmay contain the same information as ''Providerlocation address State name''. Provider BusinessMailing AddressPostal Code 94143 The postal ZIP or zone code in the mailing addressof the provider being identified. NOTE: ZIP codeplus 4-digit extension, if available. This data elementmay contain the same information as ''Providerlocation address postal code''. Provider BusinessMailing AddressCountry Code US The country code in the mailing address of theprovider being identified. This data element maycontain the same information as ''Provider locationaddress country code''. Provider BusinessMailing AddressTelephone Number 415-502-5825 The telephone number associated with mailingaddress of the provider being identified. This dataelement may contain the same information as''Provider location address telephone number''. Provider First LineBusiness PracticeLocation Address 550 16TH ST FL 5 The first line location address of the provider beingidentified. For providers with more than one physicallocation, this is the primary location. This addresscannot include a Post Office box. Provider BusinessPractice LocationAddress City Name SAN FRANCISCO The city name in the location address of the providerbeing identified. Provider BusinessPractice LocationAddress State Name CA The State or Province name in the location addressof the provider being identified. Provider BusinessPractice LocationAddress Postal Code 94143-2549 The postal ZIP or zone code in the location addressof the provider being identified. NOTE: ZIP codeplus 4-digit extension, if available. Provider BusinessPractice LocationAddress Country Code US The country code in the location address of theprovider being identified. Provider BusinessPractice LocationAddress TelephoneNumber 415-502-5825 The telephone number associated with the locationaddress of the provider being identified. Provider EnumerationDate 06/12/2008 The date the provider was assigned a uniqueidentifier (assigned an NPI). Last Update Date 01/15/2019 The date that a record was last updated or changed. Provider Gender Code F The code designating the provider's gender if theprovider is a person. Provider Gender Female The provider's gender if the provider is a person. Healthcare ProviderTaxonomy Code #1 208000000X The Health Care Provider Taxonomy code is aunique alphanumeric code, ten characters in length.The code set is structured into three distinct "Levels"including Provider Type, Classification, and Area ofSpecialization. Healthcare ProviderTaxonomy 1 Pediatrics Healthcare Provider Taxonomy #1 Provider LicenseNumber 1 A109795 Certain taxonomy selections will require you to enteryour license number and the state where the licensewas issued. Select Foreign Country in the state dropdown box if the license was issued outside of UnitedStates. The License Number field allows thefollowing special characters: ampersand,apostrophe, colon, comma, forward slash, hyphen,left and right parentheses, period, pound sign,quotation mark, and semi-colon. A field cannotcontain all special characters. DO NOT report theSocial Security Number (SSN), IRS IndividualTaxpayer Identification Number (ITIN) in thissection. Provider LicenseNumber State Code 1 CA Provider License Number State Code #1 Healthcare ProviderPrimary TaxonomySwitch 1 N Primary Taxonomy:&#xul00;&#xli00; &#x/li0;Answered;&#xli00; &#x/li0;(there can be only one per NPI record);&#xli00; &#x/li0;taxonomy.&#x/ul0; Healthcare ProviderTaxonomy Code 2 2080P0203X Healthcare Provider Taxonomy Code #2 Healthcare ProviderTaxonomy 2 Pediatric Critical CareMedicine Healthcare Provider Taxonomy #2 Provider LicenseNumber 2 A109795 Provider License Number #2 Provider LicenseNumber State Code 2 CA Provider License Number State Code #2 Healthcare ProviderPrimary TaxonomySwitch 2 Y Primary Taxonomy:&#xul00;&#xli00; &#x/li0;Answered;&#xli00; &#x/li0;(there can be only one per NPI record);&#xli00; &#x/li0;taxonomy.&#x/ul0; NPPES National Plan & Enumeration System1-800-465-3203 (NPI Toll-Free)1-800-692-2326 (NPI TTY)NPI EnumeratorPO Box 6059Fargo, ND 58108-6059Email: customerservice@npienumerator.com http://www.hipaaspace.com.