1659374601 NPI number — WENDY TIPTON OBERDICK MD

Table of content: WENDY TIPTON OBERDICK MD (NPI 1659374601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659374601 NPI number — WENDY TIPTON OBERDICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBERDICK
Provider First Name:
WENDY
Provider Middle Name:
TIPTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIPTON
Provider Other First Name:
WENDY
Provider Other Middle Name:
NANETTE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659374601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/23/2005
NPI Reactivation Date:
05/24/2005

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37662-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-857-2066
Provider Business Mailing Address Fax Number:
423-857-2070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W STONE DR
Provider Second Line Business Practice Location Address:
STE 1F
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-230-2420
Provider Business Practice Location Address Fax Number:
423-230-2422
Provider Enumeration Date:
05/23/2005

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: 207Q00000X , with the licence number:  MD46567 , 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: MD200133 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 200133 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1520114 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1623512 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".