1689737181 NPI number — SAM DAVID BERNARD M.A., PH.D.

Table of content: SAM DAVID BERNARD M.A., PH.D. (NPI 1689737181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689737181 NPI number — SAM DAVID BERNARD M.A., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNARD
Provider First Name:
SAM
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., PH.D.
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:
1689737181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 BRENTLY WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-4454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-322-3297
Provider Business Mailing Address Fax Number:
423-370-0018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6148 LEE HWY
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-2994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-322-3297
Provider Business Practice Location Address Fax Number:
423-370-0018
Provider Enumeration Date:
12/18/2006

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: 101YM0800X , with the licence number:  27004 NBCC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PE1378 , 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)





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