1477078962 NPI number — JEFFREY E BANHAM NP

Table of content: JEFFREY E BANHAM NP (NPI 1477078962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477078962 NPI number — JEFFREY E BANHAM NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANHAM
Provider First Name:
JEFFREY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1477078962
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 1000 DEPT 978
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38148-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-758-9900
Provider Business Mailing Address Fax Number:
901-752-2335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2589 APPLING RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38133-5099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-752-2300
Provider Business Practice Location Address Fax Number:
901-249-8871
Provider Enumeration Date:
08/07/2017

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: 363LF0000X , with the licence number:  22959 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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