1770572893 NPI number — WAYNE M WOODBURY 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 1770572893 NPI number — WAYNE M WOODBURY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODBURY
Provider First Name:
WAYNE
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:
1770572893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 E SPRINGBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-1761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-794-5580
Provider Business Mailing Address Fax Number:
423-232-8561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 MARKETPLACE DR STE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-2596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-794-5580
Provider Business Practice Location Address Fax Number:
423-232-8561
Provider Enumeration Date:
10/20/2005

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: 208100000X , with the licence number:  042978 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: 8397828-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: 24642 , 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)

  • Identifier: 000729385A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 552387 . This is a "WELLCARE MEDICAID & MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000729385C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000729385D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01352928 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q010272 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: G42978 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00795760 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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