1043207020 NPI number — TAVIS J TAYLOR M.D.

Table of content: TAVIS J TAYLOR M.D. (NPI 1043207020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043207020 NPI number — TAVIS J TAYLOR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
TAVIS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1043207020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3036 PERRY AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-5349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-627-8493
Provider Business Mailing Address Fax Number:
360-627-7920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3036 PERRY AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-5349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-627-8493
Provider Business Practice Location Address Fax Number:
360-627-7920
Provider Enumeration Date:
10/04/2005

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: 207R00000X , with the licence number:  MD00030507 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 128813 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 263080490 . This is a "KPS HEALTHPLANS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8241556 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91114366509 . This is a "KPS HEALTHPLANS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 91114366598310A009 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: TA7118 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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