1790740868 NPI number — EVELYN SALISBURY MIDDLETON MD

Table of content: EVELYN SALISBURY MIDDLETON MD (NPI 1790740868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790740868 NPI number — EVELYN SALISBURY MIDDLETON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIDDLETON
Provider First Name:
EVELYN
Provider Middle Name:
SALISBURY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SALISBURY
Provider Other First Name:
EVELYN
Provider Other Middle Name:
E.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790740868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNFORDVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-524-7231
Provider Business Mailing Address Fax Number:
270-524-7415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 WEST SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNFORDVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-524-7231
Provider Business Practice Location Address Fax Number:
270-524-7415
Provider Enumeration Date:
04/20/2006

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: 208000000X , with the licence number:  19100 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000046107 . This is a "ANTHUB BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64191000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1064170 . This is a "PASSPORT MEDICAID MGDCARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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