1023380946 NPI number — MR. STEWART BLAKE SCOGGIN PTA

Table of content: MR. STEWART BLAKE SCOGGIN PTA (NPI 1023380946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023380946 NPI number — MR. STEWART BLAKE SCOGGIN PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOGGIN
Provider First Name:
STEWART
Provider Middle Name:
BLAKE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1023380946
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 SANDSTONE CIR APT 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72802-7104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-675-6680
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 DETROIT ST
Provider Second Line Business Practice Location Address:
CHAMBERS MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-495-6252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2012

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: 225200000X , with the licence number:  PTA 2544 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 189733721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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