1356348213 NPI number — DR. CHARLES D JARBOE MD

Table of content: DR. CHARLES D JARBOE MD (NPI 1356348213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356348213 NPI number — DR. CHARLES D JARBOE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JARBOE
Provider First Name:
CHARLES
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1356348213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/28/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
912 WALLACE AVE STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEITCHFIELD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42754-2405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-230-8200
Provider Business Mailing Address Fax Number:
270-230-0882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 WALLACE AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-2404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-230-8200
Provider Business Practice Location Address Fax Number:
270-230-0882
Provider Enumeration Date:
07/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  22717 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000222830 . This is a "ANTHEM PIN #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 10804168 . This is a "CAQH UNIVERSAL CREDENTIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 320012117 . This is a "TAX ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 18D0999959 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64227176 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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