1194980839 NPI number — DR. KELTON STEWART FISHER JR. DPH

Table of content: DR. KELTON STEWART FISHER JR. DPH (NPI 1194980839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194980839 NPI number — DR. KELTON STEWART FISHER JR. DPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHER
Provider First Name:
KELTON
Provider Middle Name:
STEWART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISHER
Provider Other First Name:
KELTON
Provider Other Middle Name:
STEWART
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
DPH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194980839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1396 HATCHER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38401-3568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-381-1395
Provider Business Mailing Address Fax Number:
931-388-6771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1396 HATCHER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38401-3568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-381-1395
Provider Business Practice Location Address Fax Number:
931-388-6771
Provider Enumeration Date:
07/22/2008

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: 183500000X , with the licence number:  256 , 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)





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