1700179975 NPI number — MR. JACK OLIVER MCGAHEY

Table of content: MR. JACK OLIVER MCGAHEY (NPI 1700179975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700179975 NPI number — MR. JACK OLIVER MCGAHEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGAHEY
Provider First Name:
JACK
Provider Middle Name:
OLIVER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1700179975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5706 WYALONG DR
Provider Second Line Business Mailing Address:
HARRIS TEETER #174
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28227-7843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-545-4106
Provider Business Mailing Address Fax Number:
704-545-9526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5706 WYALONG DR
Provider Second Line Business Practice Location Address:
HARRIS TEETER #174
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28227-7843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-545-4106
Provider Business Practice Location Address Fax Number:
704-545-9526
Provider Enumeration Date:
05/22/2011

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: 183500000X , with the licence number:  15393 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0601006 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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