1316024193 NPI number — MID-SOUTH RECTAL CLINIC, INC.

Table of content: (NPI 1316024193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316024193 NPI number — MID-SOUTH RECTAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-SOUTH RECTAL CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316024193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7550 LUCERNE DR
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
MIDDLEBURG HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44130-6588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-234-8833
Provider Business Mailing Address Fax Number:
440-234-3313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6563 STAGE OAKS DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BARTLETT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38134-2886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-362-5252
Provider Business Practice Location Address Fax Number:
901-369-4775
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
901-362-5252

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  36972 , 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: 155546001 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3727193 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01702559 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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