1003079534 NPI number — PAUL J. TARDY

Table of content: (NPI 1003079534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003079534 NPI number — PAUL J. TARDY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL J. TARDY
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:
PT THE OT
Provider Other Organization Name Type Code:
5
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:
1003079534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 SERENDIPITY WAY # D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-6999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-556-3911
Provider Business Mailing Address Fax Number:
866-887-4617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 SERENDIPITY WAY # D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072-6999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-556-3911
Provider Business Practice Location Address Fax Number:
866-887-4617
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TARDY
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER - OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
803-556-3911

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  3735 , 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: 099039 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 11513654 . This is a "CAQH" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: P00393431 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 266140000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA49980 . This is a "HARVARD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 7052332 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: TH2387 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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