1659364669 NPI number — LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC

Table of content: MELISSA LEANNE CUSSANS PTA (NPI 1639810401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659364669 NPI number — LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC
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:
1659364669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 MAGNOLIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37352-8373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-759-5044
Provider Business Mailing Address Fax Number:
931-759-5042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 MAGNOLIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37352-8373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-759-5044
Provider Business Practice Location Address Fax Number:
931-759-5042
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STEGALL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
DWIGHT
Authorized Official Title or Position:
PA C
Authorized Official Telephone Number:
931-759-5044

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0872 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4090439 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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