1548236409 NPI number — FLETCHER M STEVENSON CRNA

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 1548236409 NPI number — FLETCHER M STEVENSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENSON
Provider First Name:
FLETCHER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1548236409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 1ST AVE
Provider Second Line Business Mailing Address:
ST MARYS HOSPTAL ROOM 6019
Provider Business Mailing Address City Name:
HUNTINGTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25702-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-399-0137
Provider Business Mailing Address Fax Number:
304-399-0138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 1ST AVE
Provider Second Line Business Practice Location Address:
ST MARYS HOSPTAL ROOM 6019
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25702-1241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-399-0137
Provider Business Practice Location Address Fax Number:
304-399-0138
Provider Enumeration Date:
02/28/2006

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: 367500000X , with the licence number:  APN10713 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN143453 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN170816 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 69677 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 270052997003 . This is a "TRICARE GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2802800 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1071314 . This is a "BRICKSTREET" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810008135 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4078445 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0207026000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001706470 . This is a "MSBCBS GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2460484 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001945814 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 27005299700 . This is a "BRICKSTREET GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3630211 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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