1558340844 NPI number — CLINTON JED BLAINE P.A.

Table of content: CLINTON JED BLAINE P.A. (NPI 1558340844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558340844 NPI number — CLINTON JED BLAINE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAINE
Provider First Name:
CLINTON
Provider Middle Name:
JED
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1558340844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 405827
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-5800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-227-3255
Provider Business Mailing Address Fax Number:
901-227-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3295 POPLAR AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38111-4690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-327-8713
Provider Business Practice Location Address Fax Number:
901-327-8284
Provider Enumeration Date:
01/13/2006

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: 363A00000X , with the licence number:  PA892 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA161186 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PA892 . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: R168894 , issued by the state of ( OR ) . This identifiers is of the category "MEDICARE PIN".
  • Identifier: 103I977461 , issued by the state of ( TN ) . This identifiers is of the category "MEDICARE PIN".
  • Identifier: 1558340844 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3380640 . This is a "GROUP MEDICAID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3380640 . This is a "GROUP MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1509074 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".