1720299274 NPI number — ANN ELDRIDGE

Table of content: ANN ELDRIDGE (NPI 1720299274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720299274 NPI number — ANN ELDRIDGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELDRIDGE
Provider First Name:
ANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1720299274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51322
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42102-5622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-777-9283
Provider Business Mailing Address Fax Number:
270-777-9283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2580 LIN DO CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-905-4427
Provider Business Practice Location Address Fax Number:
803-905-4431
Provider Enumeration Date:
05/25/2007

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: 103K00000X , with the licence number:  1-06-3099 , 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: EX6560 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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