1023057650 NPI number — KELLY AMYX MSOT

Table of content: KELLY AMYX MSOT (NPI 1023057650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023057650 NPI number — KELLY AMYX MSOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMYX
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOT
Provider Gender Code:
F

Provider's Other Name Information

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:

NPI Number Information

NPI Number:
1023057650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 681478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-1478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-800-9147
Provider Business Mailing Address Fax Number:
615-591-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37148-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-323-7575
Provider Business Practice Location Address Fax Number:
615-323-0677
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  2969 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4220815 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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