1699707638 NPI number — JOHN R WHITWORTH M.D.

Table of content: JOHN R WHITWORTH M.D. (NPI 1699707638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699707638 NPI number — JOHN R WHITWORTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITWORTH
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1699707638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2670 UNION AVENUE EXT
Provider Second Line Business Mailing Address:
SUITE 1220
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38112-4426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-458-9785
Provider Business Mailing Address Fax Number:
901-458-8192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 ESTATE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-0600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-681-4017
Provider Business Practice Location Address Fax Number:
901-681-4013
Provider Enumeration Date:
07/07/2006

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: 2080P0206X , with the licence number:  34143 , 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: 98990 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 02724221 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4128673 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3387689 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: H41886 . This is a "HEALTHSOURCE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 19169 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4128673 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 185482 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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