1215977822 NPI number — DR. WILLIAM ANTHONY BACIGALUPO

Table of content: DR. WILLIAM ANTHONY BACIGALUPO (NPI 1215977822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215977822 NPI number — DR. WILLIAM ANTHONY BACIGALUPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACIGALUPO
Provider First Name:
WILLIAM
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1215977822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 US HIGHWAY 51 BYP W
Provider Second Line Business Mailing Address:
PMB 773
Provider Business Mailing Address City Name:
DYERSBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38024-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-286-2744
Provider Business Mailing Address Fax Number:
731-285-3235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HWY 51 BYPASS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYERSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-286-2744
Provider Business Practice Location Address Fax Number:
731-285-3235
Provider Enumeration Date:
06/08/2006

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: 152W00000X , with the licence number:  OD829 , 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: 1060656 . This is a "CIGNA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3594813 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6206 . This is a "TLC MEMPHIS MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4105813 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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