1730183443 NPI number — DR. ELISA M SPRADLIN M.D.

Table of content: DR. ELISA M SPRADLIN M.D. (NPI 1730183443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730183443 NPI number — DR. ELISA M SPRADLIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPRADLIN
Provider First Name:
ELISA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1730183443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W DEAN KEETON ST STOP A101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78712-1091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-475-8235
Provider Business Mailing Address Fax Number:
512-475-9693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W DEAN KEETON ST STOP A101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78712-1091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-475-8235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2005

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: 207Q00000X , with the licence number:  L-0503 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: E-1889 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136209001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6576964003 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00126582 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1631281 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200026540A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5K950 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 04070022700 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 7976182 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2015989 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 09555297 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com