1033300173 NPI number — JEREMY WAYNE GATLIN

Table of content: (NPI 1033300173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033300173 NPI number — JEREMY WAYNE GATLIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEREMY WAYNE GATLIN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1033300173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 SAINT JOHN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DYERSBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38024-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-288-9628
Provider Business Mailing Address Fax Number:
731-288-9653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 US HIGHWAY 51 BYP W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYERSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38024-1949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-288-9628
Provider Business Practice Location Address Fax Number:
731-288-9653
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GATLIN
Authorized Official First Name:
JILL
Authorized Official Middle Name:
CHRISTINE
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
731-288-9628

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1900 , 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: 3972980 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com