1639273634 NPI number — JENNIFER L HANNUM MD

Table of content: JENNIFER L HANNUM MD (NPI 1639273634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639273634 NPI number — JENNIFER L HANNUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANNUM
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1639273634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON-SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27102-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-2255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WAKE FOREST UNIVERSITY HEALTH SCIENCES
Provider Second Line Business Practice Location Address:
MEDICAL CENTER BOULEVARD
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27157-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-716-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2006

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: 207P00000X , with the licence number:  2007-01370 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 810636 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 202020 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 146F4 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908092 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639273634 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9772074 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q0137D , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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