1194774646 NPI number — DR. JERRY CANNADAY DO

Table of content: DR. JERRY CANNADAY DO (NPI 1194774646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194774646 NPI number — DR. JERRY CANNADAY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNADAY
Provider First Name:
JERRY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1194774646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 CORDOBA CENTER DR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
HOT SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71909-4030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-915-0837
Provider Business Mailing Address Fax Number:
501-915-0978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 CORDOBA CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71909-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-915-0837
Provider Business Practice Location Address Fax Number:
501-915-0978
Provider Enumeration Date:
05/10/2006

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: 207Q00000X , with the licence number:  D7542 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: R-4722 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: R-4722 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 84Z865 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1341125-04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080095891 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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