1679620470 NPI number — MARK M KRAKAUER MD

Table of content: MARK M KRAKAUER MD (NPI 1679620470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679620470 NPI number — MARK M KRAKAUER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRAKAUER
Provider First Name:
MARK
Provider Middle Name:
M
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:
1679620470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 WOODMONT BLVD
Provider Second Line Business Mailing Address:
SUITE LL50
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-386-2300
Provider Business Mailing Address Fax Number:
615-386-2399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4230 HARDING RD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37205-2013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-297-2700
Provider Business Practice Location Address Fax Number:
615-269-4584
Provider Enumeration Date:
01/04/2007

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: 207R00000X , with the licence number:  42728 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 42728 , 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: 9726151 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1507300 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5537973 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 12702776 . This is a "PHCS/MULTIPLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00634255 . This is a "MEDICARE RR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 01228364 . This is a "AMERIGROUP TNCARE ONLY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1100835730 . This is a "USA PPO/GEHA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100077090 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1103297 . This is a "USA MCO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1920691 . This is a "COVENTRY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 2904149 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4191997 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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