1093786170 NPI number — JOHN T ST. CLAIR JR.

Table of content: JOHN T ST. CLAIR JR. (NPI 1093786170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093786170 NPI number — JOHN T ST. CLAIR JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. CLAIR
Provider First Name:
JOHN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

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:
1093786170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 S CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-4176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-935-3990
Provider Business Mailing Address Fax Number:
870-935-0871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 S CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-4176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-935-3990
Provider Business Practice Location Address Fax Number:
870-935-0871
Provider Enumeration Date:
01/27/2006

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: 207VG0400X , with the licence number:  R1950 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 770138701 . This is a "EDS BREASTCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 54635 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 3831645 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: AS0140129 . This is a "HUMANA TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12874000040 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 101682001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160027630 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com