1114096963 NPI number — MR. CHRISTOPHER L SURRATT APRN

Table of content: MR. CHRISTOPHER L SURRATT APRN (NPI 1114096963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114096963 NPI number — MR. CHRISTOPHER L SURRATT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURRATT
Provider First Name:
CHRISTOPHER
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1114096963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 MEDICAL DR
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
BLYTHEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72315-1425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-838-7385
Provider Business Mailing Address Fax Number:
870-762-4781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-1425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-838-7385
Provider Business Practice Location Address Fax Number:
870-762-4781
Provider Enumeration Date:
11/07/2006

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: 363LF0000X , with the licence number:  A01707 , 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: 160962758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5X469 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 022545600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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