1518069624 NPI number — CONSTANCE ANN GRAZIANO BS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518069624 NPI number — CONSTANCE ANN GRAZIANO BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAZIANO
Provider First Name:
CONSTANCE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURNS
Provider Other First Name:
CONSTANCE
Provider Other Middle Name:
GRAZINO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518069624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 BROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501-3603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-863-1132
Provider Business Mailing Address Fax Number:
228-865-1700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 BROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-863-1132
Provider Business Practice Location Address Fax Number:
228-865-1700
Provider Enumeration Date:
09/01/2006

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00018213 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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