1245585405 NPI number — MR. PATRICK C HARRELL CRNA

Table of content: MR. PATRICK C HARRELL CRNA (NPI 1245585405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245585405 NPI number — MR. PATRICK C HARRELL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRELL
Provider First Name:
PATRICK
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
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:
1245585405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 WOODCREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72404-9567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-243-2938
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 EXETER RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-2954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-818-2183
Provider Business Practice Location Address Fax Number:
901-682-9522
Provider Enumeration Date:
07/13/2012

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: 163W00000X , with the licence number:  R81788 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 16912 , 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: C002934 , 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: 193905001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245585405 . This is a "CHAMPUS/TRICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4331670 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 05582309 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1529774 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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