1629143342 NPI number — JASON SAMUEL CHARTERED

Table of content: (NPI 1629143342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629143342 NPI number — JASON SAMUEL CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JASON SAMUEL CHARTERED
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:
1629143342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/28/2015
NPI Reactivation Date:
05/18/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-826-1266
Provider Business Mailing Address Fax Number:
270-827-5385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 THIRD ST
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-826-1266
Provider Business Practice Location Address Fax Number:
270-827-5385
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUEL
Authorized Official First Name:
JASON
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-826-1266

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100038670 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200893090A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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