1275841488 NPI number — YOUTHCARE PEDIATRICS

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 1275841488 NPI number — YOUTHCARE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUTHCARE PEDIATRICS
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:
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:
1275841488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 MIDWAY MEDICAL PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-1664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-968-4007
Provider Business Mailing Address Fax Number:
423-652-2590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 MIDWAY MEDICAL PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-968-4007
Provider Business Practice Location Address Fax Number:
423-652-2590
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MITORAJ
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-968-4007

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  021345 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3060577 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0123498 . This is a "BLUE CROSS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 042029 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006746080 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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