1750464442 NPI number — JAMIE WAYNE MANER M.D.

Table of content: SYLVIA LAUDERDALE (NPI 1700660362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750464442 NPI number — JAMIE WAYNE MANER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANER
Provider First Name:
JAMIE
Provider Middle Name:
WAYNE
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:
1750464442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4401 W MEMORIAL RD
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73134-1785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-751-4664
Provider Business Mailing Address Fax Number:
405-749-4561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 TOWSON AVE
Provider Second Line Business Practice Location Address:
ER DEPT.
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72901-4921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-441-5011
Provider Business Practice Location Address Fax Number:
405-749-4561
Provider Enumeration Date:
10/24/2006

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: 207P00000X , with the licence number:  E-4182 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5N314 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 200098800A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157769001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".