1386752566 NPI number — ANITA LOUISE CALLICOAT NP-C

Table of content: ANITA LOUISE CALLICOAT NP-C (NPI 1386752566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386752566 NPI number — ANITA LOUISE CALLICOAT NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLICOAT
Provider First Name:
ANITA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

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:
1386752566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 OAKWOOD ESTS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTT DEPOT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25560-9730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-610-7488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 MACCORKLE AVE SE # 151
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-460-3567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2006

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: 363LF0000X , with the licence number:  59045 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 208017790 . This is a "UMWA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 20801779000 . This is a "WV WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 613154600 . This is a "BLACL LUNG" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00720801 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2821307 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810006599 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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