1629071352 NPI number — THERATECH INC

Table of content: (NPI 1629071352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629071352 NPI number — THERATECH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERATECH INC
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:
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:
1629071352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1109 MYATT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-2453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-865-4000
Provider Business Mailing Address Fax Number:
615-860-5900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 MYATT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37115-2453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-865-4000
Provider Business Practice Location Address Fax Number:
615-860-5900
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-865-4000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0000000716 , 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: 01039232 . This is a "AMERIGROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1012928 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1452177 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200312100A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0440454 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100252408-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: DM0959 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20454 . This is a "TLC MEMPHIS MANAGED CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3069828 . This is a "BLUE CROSS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 148218716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90001355 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009712930 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00977545A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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