1164473005 NPI number — PERRY JERNIGAN M.D.

Table of content: PERRY JERNIGAN M.D. (NPI 1164473005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164473005 NPI number — PERRY JERNIGAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERNIGAN
Provider First Name:
PERRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1164473005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 SUNSET DR
Provider Second Line Business Mailing Address:
STE 3
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-7906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-926-4966
Provider Business Mailing Address Fax Number:
423-926-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 SUNSET DR
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-7906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-926-4966
Provider Business Practice Location Address Fax Number:
423-926-1823
Provider Enumeration Date:
05/15/2006

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: 2085R0202X , with the licence number:  30603 , 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: 3828412 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64305642 . This is a "KENTUCKY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7222688 . This is a "VIRGINIA MEDICAID" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 3098340 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 89063JH . This is a "NORTH CAROLINA MEDICAID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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