Basic Information
| Provider Information | |||||||||
| NPI: | 1962561936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VOMACKA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1604 SOUTH FIRST STREET | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315079 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 SOUTH FIRST STREET | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315079 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 06/14/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 36746 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1521082 | 01 | UBH | OTHER | 9F414VO | 01 | BLUE CROSS | OTHER | 1013089 | 01 | PREFERRED ONE | OTHER | 115359 | 01 | UCARE | OTHER |