1255463949 NPI number — VANDERBILT INTEGRATED PROVIDERS

Table of content: (NPI 1255463949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255463949 NPI number — VANDERBILT INTEGRATED PROVIDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANDERBILT INTEGRATED PROVIDERS
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:
PEDIATRIC ASSOCIATES
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:
1255463949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 HIGH STREET
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-885-8445
Provider Business Mailing Address Fax Number:
270-886-9106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 HIGH STREET
Provider Second Line Business Practice Location Address:
SUITE 3A
Provider Business Practice Location Address City Name:
HOPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-885-8445
Provider Business Practice Location Address Fax Number:
270-886-9106
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WESTBROOK
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
615-936-5187

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 3002428 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: 3004549 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 78900800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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