1629082250 NPI number — SAMUEL L ERWIN

Table of content: SAMUEL L ERWIN (NPI 1629082250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629082250 NPI number — SAMUEL L ERWIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERWIN
Provider First Name:
SAMUEL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1629082250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORNING
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72422-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-857-6556
Provider Business Mailing Address Fax Number:
870-857-3787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 N MISSOURI AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72422-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-857-6556
Provider Business Practice Location Address Fax Number:
870-857-3787
Provider Enumeration Date:
07/28/2006

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: 152W00000X , with the licence number:  2293 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 291690 . This is a "PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 101510722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".