Basic Information
| Provider Information | |||||||||
| NPI: | 1356876502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDEAL OPTION, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8656 W GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
| FaxNumber: | 5094913031 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 N ROLLING RD | ||||||||
| Address2: | # 301 | ||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
| FaxNumber: | 5094913031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2017 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLGAIER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5092221275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | D0082238 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207LA0401X | D0082182 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 424394300 | 05 | MD | MEDICAID |