1568534428 NPI number — KELLEY VON SCOTT APN

Table of content: KELLEY VON SCOTT APN (NPI 1568534428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568534428 NPI number — KELLEY VON SCOTT APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
KELLEY
Provider Middle Name:
VON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1568534428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6078 FLYNTHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38135-2314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-385-6257
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3362 S 3RD ST
Provider Second Line Business Practice Location Address:
CHRIST COMMUNITY HEALTH SERVICES INC
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38109-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-271-6300
Provider Business Practice Location Address Fax Number:
901-260-8590
Provider Enumeration Date:
11/15/2006

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: 363L00000X , with the licence number:  APN0000008317 , 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: 1509516 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com