1366561763 NPI number — HENRY COUNTY FAMILY PHYSICIANS INC

Table of content: MR. PICKENS ALLISON GANTT III LAC (NPI 1548732985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366561763 NPI number — HENRY COUNTY FAMILY PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENRY COUNTY FAMILY PHYSICIANS INC
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:
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:
1366561763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 E RIVERVIEW AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NAPOLEON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43545-9805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-592-8774
Provider Business Mailing Address Fax Number:
419-592-4103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 E RIVERVIEW AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
NAPOLEON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43545-9805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-592-8774
Provider Business Practice Location Address Fax Number:
419-592-4103
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNIPE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
419-592-8774

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0839178 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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