1124308473 NPI number — TYLER L ROBERTSON CRNA

Table of content: TYLER L ROBERTSON CRNA (NPI 1124308473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124308473 NPI number — TYLER L ROBERTSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
TYLER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1124308473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 52404
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-429-5071
Provider Business Mailing Address Fax Number:
256-429-4674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HOSPITAL DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35801-6455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-429-5071
Provider Business Practice Location Address Fax Number:
256-429-4674
Provider Enumeration Date:
08/18/2011

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:  APN16057 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: RN169321 , 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: 1-113384 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4306609 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 133589 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003114495A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".