1568503993 NPI number — EAST TENNESSEE WOUND CARE PC

Table of content: (NPI 1568503993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568503993 NPI number — EAST TENNESSEE WOUND CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE WOUND CARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1568503993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40257-8180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-753-0680
Provider Business Mailing Address Fax Number:
502-753-0687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4950 NORTON HEALTHCARE BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-446-6160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIRK
Authorized Official First Name:
CARY
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
502-930-9861

Provider Taxonomy Codes

  • Taxonomy code: 2083P0011X , with the licence number:  21368 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2789407000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: DF7517 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000487847 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200828020A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50012967 . This is a "PASSPORT HEALTH PLANS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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