1578513040 NPI number — MRS. SHAWN ROONEY GRAY MSN

Table of content: MRS. SHAWN ROONEY GRAY MSN (NPI 1578513040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578513040 NPI number — MRS. SHAWN ROONEY GRAY MSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
SHAWN
Provider Middle Name:
ROONEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROONEY
Provider Other First Name:
SHAWN
Provider Other Middle Name:
FONTENOT
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578513040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
857 E. VIRGINIA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-880-8466
Provider Business Mailing Address Fax Number:
409-880-7703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
857 E. VIRGINIA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-880-8466
Provider Business Practice Location Address Fax Number:
409-880-7703
Provider Enumeration Date:
05/12/2006

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: 363L00000X , with the licence number:  618115 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8N9839 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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