1093721037 NPI number — DEAN E WHITLEY NP

Table of content: DEAN E WHITLEY NP (NPI 1093721037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093721037 NPI number — DEAN E WHITLEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITLEY
Provider First Name:
DEAN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1093721037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2742
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39130-2742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-853-8814
Provider Business Mailing Address Fax Number:
601-853-8816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
794 HIGHWAY 51
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39110-9662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-853-8814
Provider Business Practice Location Address Fax Number:
601-853-8816
Provider Enumeration Date:
07/31/2006

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: 363LF0000X , with the licence number:  R613053 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01656530 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com