1720246887 NPI number — DR. TAYLOR S PRUETT M.D.

Table of content: DR. TAYLOR S PRUETT M.D. (NPI 1720246887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720246887 NPI number — DR. TAYLOR S PRUETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUETT
Provider First Name:
TAYLOR
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1720246887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 FLOWOOD DR STE 402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-9307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-936-1395
Provider Business Mailing Address Fax Number:
601-936-1260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 RIVER OAKS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-376-2832
Provider Business Practice Location Address Fax Number:
601-376-1816
Provider Enumeration Date:
05/27/2008

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: 208M00000X , with the licence number:  21099 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 21099 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 156867 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01228873 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 05638761 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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