1235130816 NPI number — PRI-MED INCORPORATED

Table of content: (NPI 1235130816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235130816 NPI number — PRI-MED INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRI-MED INCORPORATED
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:
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:
1235130816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1918 EXETER RD
Provider Second Line Business Mailing Address:
STE-2
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38138-2970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-624-5911
Provider Business Mailing Address Fax Number:
901-624-5637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1918 EXETER RD
Provider Second Line Business Practice Location Address:
STE-2
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-2970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-624-5911
Provider Business Practice Location Address Fax Number:
901-624-5637
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
MAX
Authorized Official Middle Name:
F
Authorized Official Title or Position:
GENERAL MANAGEER
Authorized Official Telephone Number:
901-624-5911

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 158399 . This is a "BETTER HEALTH PLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 32656 . This is a "TLC FAMILY HEALTH PLANS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 99663 . This is a "BCBS-AR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 4087579 . This is a "BCBS-TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1454502 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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