1003089830 NPI number — MRS. MARY ELLEN TUITT R.D.

Table of content: MRS. MARY ELLEN TUITT R.D. (NPI 1003089830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003089830 NPI number — MRS. MARY ELLEN TUITT R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUITT
Provider First Name:
MARY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.D.
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:
1003089830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-718-6770
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1710 KERNERSVILLE MEDICAL PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
KERNERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27284-7157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-718-6770
Provider Business Practice Location Address Fax Number:
336-277-1889
Provider Enumeration Date:
04/13/2008

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: 133V00000X , with the licence number:  L001136 , 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: 2993130 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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