1265954424 NPI number — IN CHARGE MEDICAL PROFESSIONALS TN,PC

Table of content: (NPI 1265954424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265954424 NPI number — IN CHARGE MEDICAL PROFESSIONALS TN,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IN CHARGE MEDICAL PROFESSIONALS TN,PC
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:
1265954424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2741 W LAYTON AVE STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-242-5468
Provider Business Mailing Address Fax Number:
888-724-0875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-312-5159
Provider Business Practice Location Address Fax Number:
888-724-0875
Provider Enumeration Date:
07/10/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CZERNEJEWSKI
Authorized Official First Name:
JODI
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
262-510-6350

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300015506 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300015508 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300014452 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300015507 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".