1215269147 NPI number — CAROL E. PETHEL CRNA

Table of content: CAROL E. PETHEL CRNA (NPI 1215269147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215269147 NPI number — CAROL E. PETHEL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETHEL
Provider First Name:
CAROL
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1215269147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 N FANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29621-5708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-512-1417
Provider Business Mailing Address Fax Number:
864-512-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 N FANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29621-5708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-512-1340
Provider Business Practice Location Address Fax Number:
864-512-1749
Provider Enumeration Date:
02/03/2010

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: 367500000X , with the licence number:  083407 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NPI # . This is a "TRICARE (HUMANA)" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: NPI/SSN . This is a "BLUECROSS BLUESHIELD OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00911158 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: AN2036 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NPI/SSN . This is a "BLUECHOICE OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 20101737 . This is a "SELECT HEALTH OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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