1245218742 NPI number — CITY OF OLIVE BRANCH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245218742 NPI number — CITY OF OLIVE BRANCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF OLIVE BRANCH
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:
1245218742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-9150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-744-9600
Provider Business Mailing Address Fax Number:
270-744-9600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9200 PIGEON ROOST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-892-9236
Provider Business Practice Location Address Fax Number:
662-892-9221
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
KEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MAYOR
Authorized Official Telephone Number:
662-892-9236

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  105 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000016581 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 4581042 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00050725 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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