1639117245 NPI number — ROBERT K MEHRLE JR. MD

Table of content: ROBERT K MEHRLE JR. MD (NPI 1639117245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639117245 NPI number — ROBERT K MEHRLE JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEHRLE
Provider First Name:
ROBERT
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1639117245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 E FORTIFICATION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39202-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-354-4488
Provider Business Mailing Address Fax Number:
601-960-4586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 E FORTIFICATION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39202-2442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-354-4488
Provider Business Practice Location Address Fax Number:
601-960-4586
Provider Enumeration Date:
06/04/2006

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: 207XS0114X , with the licence number:  17298 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 17298 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01227851 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00325234 . This is a "RROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 52I200004 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 512G700003 . This is a "UP MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 200000479 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00645611 . This is a "RR PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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