1477660967 NPI number — WILLIAM G. CRADDOCK

Table of content: (NPI 1477660967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477660967 NPI number — WILLIAM G. CRADDOCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM G. CRADDOCK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVANCED HEALTH CARE
Provider Other Organization Name Type Code:
3
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:
1477660967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 GARNER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-612-0087
Provider Business Mailing Address Fax Number:
615-612-0587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 GARNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37115-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-612-0087
Provider Business Practice Location Address Fax Number:
615-612-0587
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLINARD
Authorized Official First Name:
PETE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
615-612-0087

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0000000650 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: 0000000650 , 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: 2179198 . This is a "AETNA HMO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3035094 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9027403600 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1452195 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55770104 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100005360 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3035094 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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