1356636492 NPI number — DR. DAVID TREMBLAY M.D.

Table of content: DR. DAVID TREMBLAY M.D. (NPI 1356636492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356636492 NPI number — DR. DAVID TREMBLAY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TREMBLAY
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1356636492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 CLARITY RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-3138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-606-4990
Provider Business Mailing Address Fax Number:
843-375-1480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18850 S MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338-4288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-446-7900
Provider Business Practice Location Address Fax Number:
281-446-4879
Provider Enumeration Date:
06/16/2011

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: 207W00000X , with the licence number:  MMD 33822 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: MMD.33822 LL , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP5503 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP2156 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP2149 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP2172 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 338227 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP5351 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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