1649270844 NPI number — MR. RUDY GARY HAMM PA-C

Table of content: MR. RUDY GARY HAMM PA-C (NPI 1649270844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649270844 NPI number — MR. RUDY GARY HAMM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMM
Provider First Name:
RUDY
Provider Middle Name:
GARY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1649270844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1559 HIGHLAND PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENOIR CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37772-6237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-635-8389
Provider Business Mailing Address Fax Number:
656-358-3908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1559 HIGHLAND PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENOIR CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37772-6237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-635-8389
Provider Business Practice Location Address Fax Number:
865-635-8390
Provider Enumeration Date:
07/28/2005

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: 363AM0700X , with the licence number:  PA0000000203TN , 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: 3669684 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".