1285601344 NPI number — MAURICE EUGENE NIDA DO

Table of content: MAURICE EUGENE NIDA DO (NPI 1285601344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285601344 NPI number — MAURICE EUGENE NIDA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIDA
Provider First Name:
MAURICE
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1285601344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 EXECUTIVE PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-3250
Provider Business Mailing Address Fax Number:
423-224-3258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
295 WHARTON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-679-0321
Provider Business Practice Location Address Fax Number:
276-679-6498
Provider Enumeration Date:
03/07/2006

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: 207R00000X , with the licence number:  0102049965 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006084877 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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