1396967493 NPI number — JASON M EVANS MD

Table of content: JASON M EVANS MD (NPI 1396967493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396967493 NPI number — JASON M EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
JASON
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1396967493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
706-494-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3443 DICKERSON PIKE
Provider Second Line Business Practice Location Address:
STE 360
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37207-2519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-301-8269
Provider Business Practice Location Address Fax Number:
615-712-9823
Provider Enumeration Date:
05/02/2007

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: 207XX0801X , with the licence number:  MD46446 , 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: P01570555 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100129730 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com