1568095503 NPI number — EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN

Table of content: (NPI 1568095503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568095503 NPI number — EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN
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:
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:
1568095503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 FAIRWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-253-0000
Provider Business Mailing Address Fax Number:
650-253-0001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 PAOAKALANI AVE # 714
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96815-3764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-253-0000
Provider Business Practice Location Address Fax Number:
650-253-0001
Provider Enumeration Date:
02/18/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
CORNELIUS
Authorized Official Title or Position:
SPECIALIST TECHNOLOGIST
Authorized Official Telephone Number:
650-253-0000

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 314125401722 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".