1508193459 NPI number — MR. DAVID BENSON SUMERFORD FNP-BC, PMHNP

Table of content: MR. DAVID BENSON SUMERFORD FNP-BC, PMHNP (NPI 1508193459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508193459 NPI number — MR. DAVID BENSON SUMERFORD FNP-BC, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMERFORD
Provider First Name:
DAVID
Provider Middle Name:
BENSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC, PMHNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUMERFORD
Provider Other First Name:
BEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC, PMHNP-BC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508193459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38870-0305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-690-8007
Provider Business Mailing Address Fax Number:
662-651-4658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 GLOSTER CREEK VLG
Provider Second Line Business Practice Location Address:
SUITE D-1
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-690-8007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2009

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: 363LF0000X , with the licence number:  R884013 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 884013 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08725789 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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