1629062203 NPI number — STEVENS D MELTON MD

Table of content: STEVENS D MELTON MD (NPI 1629062203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629062203 NPI number — STEVENS D MELTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELTON
Provider First Name:
STEVENS
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629062203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 WOODLAWN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DYERSBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-287-4500
Provider Business Mailing Address Fax Number:
731-287-4804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 WOODLAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYERSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-287-4500
Provider Business Practice Location Address Fax Number:
731-287-4804
Provider Enumeration Date:
09/09/2005

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: 208000000X , with the licence number:  MD014213 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 14213 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3015669 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0052428 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8203648 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7161 . This is a "TLC (MEMPHIS MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116249 . This is a "BETTER HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1240124 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4176802 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 370008023 . This is a "PALMETTO GBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4673227 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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