1396723748 NPI number — DR. RONALD EDWIN MATTISON M.D.

Table of content: PATTY ANN GLIDEWELL (NPI 1669747820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396723748 NPI number — DR. RONALD EDWIN MATTISON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTISON
Provider First Name:
RONALD
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1396723748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6005 PARK AVE
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-5202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-527-3391
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6005 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38119-5202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-527-3391
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2006

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: 208600000X , with the licence number:  048275 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 036118870 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 45847 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135084 . This is a "HAMP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3932056 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 869299 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036118070 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7210895 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 320875 . This is a "GHP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".