1700867074 NPI number — DR. RAPHAEL A BUCKLE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700867074 NPI number — DR. RAPHAEL A BUCKLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLE
Provider First Name:
RAPHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
1700867074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 EARL FRYE BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
AMORY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38821-5507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-256-9331
Provider Business Mailing Address Fax Number:
662-256-9336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 EARL FRYE BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AMORY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38821-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-256-9331
Provider Business Practice Location Address Fax Number:
662-256-9335
Provider Enumeration Date:
11/14/2005

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: 207K00000X , with the licence number:  56408 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 56408 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 20416 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37BBHBH . This is a "LEGACY#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1184881229 . This is a "ORG NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 06304211 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1700867074 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 262717777A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GRP7462 . This is a "GROUP#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 013274000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com