1346856366 NPI number — ERIN EDGMON APRN

Table of content: ERIN EDGMON APRN (NPI 1346856366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346856366 NPI number — ERIN EDGMON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDGMON
Provider First Name:
ERIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1346856366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72650-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-448-5733
Provider Business Mailing Address Fax Number:
870-448-3767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BOSTON MOUNTAIN RURAL HEALTH CENTER INC.
Provider Second Line Business Practice Location Address:
609 W CLARK ST
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72641-0130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-446-2225
Provider Business Practice Location Address Fax Number:
870-446-2227
Provider Enumeration Date:
09/16/2020

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: 363LF0000X , with the licence number:  212623 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 254276758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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