1053374272 NPI number — ELIZABETH B WILKES CRNA

Table of content: ELIZABETH B WILKES CRNA (NPI 1053374272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053374272 NPI number — ELIZABETH B WILKES CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKES
Provider First Name:
ELIZABETH
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1053374272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-522-8603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 INDEPENDENCE PT STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-4569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-522-3700
Provider Business Practice Location Address Fax Number:
864-522-3705
Provider Enumeration Date:
04/10/2006

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: 367500000X , with the licence number:  071606 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 144591 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 20257 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00154891 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3632439 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100045577 . This is a "PHP TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 8052638 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4084219 . This is a "BLUECARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4084219 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: NAN620 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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