1477544872 NPI number — DEBRA J EADENS MD

Table of content: DEBRA J EADENS MD (NPI 1477544872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477544872 NPI number — DEBRA J EADENS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EADENS
Provider First Name:
DEBRA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1477544872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 BOGLE ST
Provider Second Line Business Mailing Address:
STE 3
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42503-2870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-451-9953
Provider Business Mailing Address Fax Number:
606-451-1533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 BOGLE ST
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-9953
Provider Business Practice Location Address Fax Number:
606-451-1533
Provider Enumeration Date:
11/03/2005

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: 207R00000X , with the licence number:  29813 , 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: 04-00404 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1183452 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 611350780 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000074702 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 37J8 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64298136 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110198804 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5520074 . This is a "CCN/AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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