1699867366 NPI number — SHARLET SLOUGH DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699867366 NPI number — SHARLET SLOUGH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHARLET SLOUGH DO
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:
1699867366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75711-8819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-617-6239
Provider Business Mailing Address Fax Number:
903-617-6249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6115 NEW COPELAND RD STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-617-6239
Provider Business Practice Location Address Fax Number:
903-617-6249
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SLOUGH
Authorized Official First Name:
SHARLET
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-617-6239

Provider Taxonomy Codes

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

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

  • Identifier: DG2129 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0055PW . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 185213901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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