1285950063 NPI number — CRAIG M. MATHERNE, M.D., A.P.M.C.

Table of content: (NPI 1285950063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285950063 NPI number — CRAIG M. MATHERNE, M.D., A.P.M.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG M. MATHERNE, M.D., A.P.M.C.
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:
1285950063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3521 HIGHWAY 190
Provider Second Line Business Mailing Address:
SUITE P
Provider Business Mailing Address City Name:
EUNICE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70535-5135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-457-8040
Provider Business Mailing Address Fax Number:
337-457-8043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3521 HIGHWAY 190
Provider Second Line Business Practice Location Address:
SUITE P
Provider Business Practice Location Address City Name:
EUNICE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70535-5135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-457-8040
Provider Business Practice Location Address Fax Number:
337-457-8043
Provider Enumeration Date:
04/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MATHERNE
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
337-457-8040

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  13221R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1558729 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DR4154 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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