1023165123 NPI number — MAC GENE BAILES DO

Table of content: MAC GENE BAILES DO (NPI 1023165123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023165123 NPI number — MAC GENE BAILES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILES
Provider First Name:
MAC
Provider Middle Name:
GENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1023165123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1431 CENTERPOINT BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37932-1984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HOYLMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASSAWAY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26624-9321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-364-1060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2007

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: 207P00000X , with the licence number:  1100 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0041340000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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