1457313439 NPI number — DR. WESLEY V EASTRIDGE MD

Table of content: DR. WESLEY V EASTRIDGE MD (NPI 1457313439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457313439 NPI number — DR. WESLEY V EASTRIDGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EASTRIDGE
Provider First Name:
WESLEY
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1457313439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1233 RADCLIFFE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37664-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-502-8656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 RADCLIFFE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37664-2027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-502-8656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2006

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: 207Q00000X , with the licence number:  0101037010 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4046651 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107277 . This is a "BLUE CROSS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 274021 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 037070 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2622550 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005609879 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4581788 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 037073 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 621584391 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4401019 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 62158439108 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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