1487762514 NPI number — TARA MARIE CRAFFEY RUTH AUD

Table of content: TARA MARIE CRAFFEY RUTH AUD (NPI 1487762514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487762514 NPI number — TARA MARIE CRAFFEY RUTH AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTH
Provider First Name:
TARA
Provider Middle Name:
MARIE CRAFFEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAFFEY
Provider Other First Name:
TARA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AUD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487762514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHESTERFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23235-8000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-484-3700
Provider Business Mailing Address Fax Number:
804-320-6462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 MAYLAND CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENRICO
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23233-1468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-484-3700
Provider Business Practice Location Address Fax Number:
804-320-6462
Provider Enumeration Date:
08/28/2006

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:  2201001318 , 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: 010318254 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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