1598817801 NPI number — FIRST CHOICE NEUROSURGERY, PC

Table of content: (NPI 1598817801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598817801 NPI number — FIRST CHOICE NEUROSURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST CHOICE NEUROSURGERY, 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:
1598817801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 W RAVINE RD
Provider Second Line Business Mailing Address:
SUITE 4-A
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-392-9300
Provider Business Mailing Address Fax Number:
423-392-9365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 W RAVINE RD
Provider Second Line Business Practice Location Address:
SUITE 4-A
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-392-9300
Provider Business Practice Location Address Fax Number:
423-392-9365
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARTMAN
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-392-9300

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , with the licence number:  139176 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 36815 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 36815 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3729788 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD3260 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4103830 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4205736 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64059660 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177322 . This is a "ANTHEM BCBS VA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 61504100 . This is a "OWCP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 9454636 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 010165610 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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