1912189085 NPI number — PEDIATRICS TO PARENTS MEDICAL, PC

Table of content: (NPI 1912189085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912189085 NPI number — PEDIATRICS TO PARENTS MEDICAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRICS TO PARENTS MEDICAL, 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:
PEDS TO PARENTS
Provider Other Organization Name Type Code:
3
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:
1912189085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 959
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW TAZEWELL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37824-0959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-626-1931
Provider Business Mailing Address Fax Number:
423-626-1948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1442 N BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
TAZEWELL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37879-4361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-626-1931
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FEJERAN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
JC
Authorized Official Title or Position:
PRESIDENT AND PHYSICIAN
Authorized Official Telephone Number:
423-626-1931

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  000999 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3303563 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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