1336209550 NPI number — J H FAIRBANKS MD PLLC

Table of content: (NPI 1336209550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336209550 NPI number — J H FAIRBANKS MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J H FAIRBANKS MD PLLC
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:
6
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:
1336209550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 FRONT ST
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
39120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-336-2212
Provider Business Mailing Address Fax Number:
318-336-6067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 FRONT ST
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
39120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-336-2212
Provider Business Practice Location Address Fax Number:
318-336-6067
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NUGENT
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
318-336-2212

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  15703 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: MD017268 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD017268 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00119142 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1384101 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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