1700861838 NPI number — JAYME L CUNDIFF CRNA

Table of content: JAYME L CUNDIFF CRNA (NPI 1700861838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700861838 NPI number — JAYME L CUNDIFF CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNDIFF
Provider First Name:
JAYME
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1700861838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 MEDICAL VILLAGE DR
Provider Second Line Business Mailing Address:
SUITE 258
Provider Business Mailing Address City Name:
EDGEWOOD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-341-7246
Provider Business Mailing Address Fax Number:
859-341-7867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 STATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45255-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-7246
Provider Business Practice Location Address Fax Number:
859-341-7867
Provider Enumeration Date:
12/13/2005

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: 367500000X , with the licence number:  172517 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000277547 . This is a "ANTHEM BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200381060 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2158187 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 728021 . This is a "BUCKEYE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 74006057 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 617571 . This is a "WELLCARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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