1427191790 NPI number — DR. EDWARD J WREN III MD

Table of content: DR. EDWARD J WREN III MD (NPI 1427191790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427191790 NPI number — DR. EDWARD J WREN III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WREN
Provider First Name:
EDWARD
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1427191790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20452
Provider Second Line Business Mailing Address:
YPS-CRED
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43220-0452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-442-2406
Provider Business Mailing Address Fax Number:
614-442-2410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 ANDRE ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
NEW IBERIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70563-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-364-9225
Provider Business Practice Location Address Fax Number:
337-364-6094
Provider Enumeration Date:
02/15/2007

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: 207L00000X , with the licence number:  015754 , 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: 1427191790 . This is a "BCBS OF LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1427191790 . This is a "RR MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1311111 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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