1558399089 NPI number — DR. JIM CARROLL BRASFIELD M.D.

Table of content: DR. JIM CARROLL BRASFIELD M.D. (NPI 1558399089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558399089 NPI number — DR. JIM CARROLL BRASFIELD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRASFIELD
Provider First Name:
JIM
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1558399089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17016
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24209-7016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-844-6407
Provider Business Mailing Address Fax Number:
423-793-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 BRISTOL BLVD W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-8765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-844-6407
Provider Business Practice Location Address Fax Number:
423-793-7004
Provider Enumeration Date:
06/30/2006

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: 207T00000X , with the licence number:  9991 , 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)

  • Identifier: 3014517 . This is a "UMWA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4005735 . This is a "BLUECROSS & BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7817131 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 006101208 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140007601 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 361712500 . This is a "DEPT OF LABOR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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