1326105586 NPI number — MATTHEW W CRAIN

Table of content: (NPI 1326105586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326105586 NPI number — MATTHEW W CRAIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTHEW W CRAIN
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:
BIO-TEK MEDICAL
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:
1326105586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3845 GOODMAN RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38672-6444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-890-6862
Provider Business Mailing Address Fax Number:
662-890-6865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3845 GOODMAN RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38672-6444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-890-6862
Provider Business Practice Location Address Fax Number:
662-890-6865
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRAIN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-890-6862

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1082062 . This is a "USA MANAGED CARE NETWORK" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 163731716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4146633 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 00303087 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 612772600 . This is a "OWCP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1455144 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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