1063428688 NPI number — ST. JUDE CHILDREN'S RESEARCH HOSPITAL

Table of content: NANCY A. NUSSMEIER M.D. (NPI 1760482053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063428688 NPI number — ST. JUDE CHILDREN'S RESEARCH HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JUDE CHILDREN'S RESEARCH HOSPITAL
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:
1063428688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7777 HENNESSY BLVD
Provider Second Line Business Mailing Address:
STE. 312
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-763-6337
Provider Business Mailing Address Fax Number:
225-761-4072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD
Provider Second Line Business Practice Location Address:
STE. 312
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-763-6337
Provider Business Practice Location Address Fax Number:
225-761-4072
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANARIOS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
901-495-3006

Provider Taxonomy Codes

  • Taxonomy code: 2080P0207X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1446131 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01554572 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2678828 . This is a "AETNA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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