1720091390 NPI number — THOMAS G TYNER CRNA

Table of content: THOMAS G TYNER CRNA (NPI 1720091390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720091390 NPI number — THOMAS G TYNER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYNER
Provider First Name:
THOMAS
Provider Middle Name:
G
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:
1720091390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29116-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-395-4499
Provider Business Mailing Address Fax Number:
803-395-4480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 ST MATTHEWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29118-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-395-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2006

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:  3012 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 576008010015 . This is a "TRICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: MM5083 . This is a "MEDICARE PART B" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: AN1516 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 576008010009 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5S867 . This is a "MEDICAE PART B" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 576008010006 . This is a "BLUE CHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 000000194021 . This is a "UNISON" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 20056087 . This is a "FIRST CHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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