1538119789 NPI number — COREY A POTTS CRNA

Table of content: COREY A POTTS CRNA (NPI 1538119789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538119789 NPI number — COREY A POTTS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTS
Provider First Name:
COREY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1538119789
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3276
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47731-3276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-473-0181
Provider Business Mailing Address Fax Number:
812-473-5822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1808 SHERMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-385-3400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2006

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: 367500000X , with the licence number:  28162089A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00219322 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200510270 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000353810 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000682757 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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