1306876099 NPI number — BREANN LYN BAILEY MD

Table of content: BREANN LYN BAILEY MD (NPI 1306876099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306876099 NPI number — BREANN LYN BAILEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
BREANN
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1306876099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RADFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24141-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-639-5188
Provider Business Mailing Address Fax Number:
540-639-9215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RADFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24141-2426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-639-5188
Provider Business Practice Location Address Fax Number:
540-639-9215
Provider Enumeration Date:
07/05/2006

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: 208000000X , with the licence number:  27148 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 0101246067 , 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: 271486 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7123334 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 379826 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 576007863102 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 7200954 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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