1265428734 NPI number — JARED Y ROBERTSON III CRNA

Table of content: JARED Y ROBERTSON III CRNA (NPI 1265428734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265428734 NPI number — JARED Y ROBERTSON III CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
JARED
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
1265428734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 JEFFERSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70121-2429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-842-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 DRINKWATER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY ST LOUIS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39520-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-467-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2005

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:  10597 , 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: 5201 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 4858A , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 24167318 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 3625 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 71550 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 144482 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 901491 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010103894 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4081487 . This is a "BLUE SHIELD OF TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 74008541 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: TN0100 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100045319 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3632282 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00013859 . This is a "NHC CARE ADMINISTRATORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 146158 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".




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