1467764779 NPI number — AMY E BENEFIELD

Table of content: AMY E BENEFIELD (NPI 1467764779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467764779 NPI number — AMY E BENEFIELD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEFIELD
Provider First Name:
AMY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1467764779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-261-3606
Provider Business Mailing Address Fax Number:
601-579-5240

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:
228-831-0050
Provider Business Practice Location Address Fax Number:
228-831-1121
Provider Enumeration Date:
07/02/2010

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: 367500000X , with the licence number:  R863937 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 1-125754 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02582807 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9963845 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1540792 . This is a "CIGNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 3476658 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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