1588693840 NPI number — DR. JAMES S GWINN JR. M.D.

Table of content: DR. JAMES S GWINN JR. M.D. (NPI 1588693840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588693840 NPI number — DR. JAMES S GWINN JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GWINN
Provider First Name:
JAMES
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1588693840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POST OFFICE BOX 7648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-7648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-467-2392
Provider Business Mailing Address Fax Number:
812-471-6650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 KENTUCKY AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42003-3817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-575-3113
Provider Business Practice Location Address Fax Number:
270-575-3135
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: 207RI0011X , with the licence number:  19484 , 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: 64194848 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060008620 . This is a "RAILROAD MEDIARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 02002740322 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2152 . This is a "KENTUCKY BLS PROVIDER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 610976324003 . This is a "CHAMPUS ID #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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