1588845259 NPI number — NEPHROLOGY ASSOCIATES, PC

Table of content: (NPI 1588845259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588845259 NPI number — NEPHROLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEPHROLOGY ASSOCIATES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1588845259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1349 N MOUNT AUBURN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63701-1727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-334-9564
Provider Business Mailing Address Fax Number:
573-334-1879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 E MOULTRIE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-6855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-776-1464
Provider Business Practice Location Address Fax Number:
870-776-1474
Provider Enumeration Date:
11/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRAXTON
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
573-334-9564

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117672 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: CI5170 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: H8238 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5C446 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".