1376650515 NPI number — MRS. CHARLENE M TAYLOR AU.D.

Table of content: MRS. CHARLENE M TAYLOR AU.D. (NPI 1376650515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376650515 NPI number — MRS. CHARLENE M TAYLOR AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
CHARLENE
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
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:
1376650515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13430 TARA HILLS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39503-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-863-6592
Provider Business Mailing Address Fax Number:
228-863-1747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3017 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-863-6592
Provider Business Practice Location Address Fax Number:
228-863-1747
Provider Enumeration Date:
08/24/2006

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: 231H00000X , with the licence number:  A2774 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 512I640011 . This is a "MEDICARE PROVIDER IDENTIFICATION NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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