1750327706 NPI number — TIFFANY K MAIN NP

Table of content: TIFFANY K MAIN NP (NPI 1750327706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750327706 NPI number — TIFFANY K MAIN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAIN
Provider First Name:
TIFFANY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1750327706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64803-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-347-6400
Provider Business Mailing Address Fax Number:
417-347-6404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1902 S US HWY 59
Provider Second Line Business Practice Location Address:
CLINIC BLDG STE 1
Provider Business Practice Location Address City Name:
PARSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-6400
Provider Business Practice Location Address Fax Number:
417-347-6404
Provider Enumeration Date:
06/20/2006

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: 363L00000X , with the licence number:  45333 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100850610A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100429300A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160904 . This is a "KS BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 425962602 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500027083 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com