1427015205 NPI number — JAMES ANTHONY CARLEN IV CRNA

Table of content: JAMES ANTHONY CARLEN IV CRNA (NPI 1427015205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427015205 NPI number — JAMES ANTHONY CARLEN IV CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLEN
Provider First Name:
JAMES
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
CRNA
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:
1427015205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2637 PINE LAKE DR
Provider Second Line Business Mailing Address:
FIRST FLOOR
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29169-3742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-2548
Provider Business Mailing Address Fax Number:
803-296-2548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 SUNSET BLVD
Provider Second Line Business Practice Location Address:
LEXINGTON MEDICAL CENTER
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-791-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2006

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: 367500000X , with the licence number:  1653 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AN1217 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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