1801896881 NPI number — DR. ELBERT EDWIN HINES III M.D.

Table of content: DR. ELBERT EDWIN HINES III M.D. (NPI 1801896881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801896881 NPI number — DR. ELBERT EDWIN HINES III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HINES
Provider First Name:
ELBERT
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
1801896881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6263 POPLAR AVE
Provider Second Line Business Mailing Address:
STE 1052
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-4736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-761-6157
Provider Business Mailing Address Fax Number:
901-761-4145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6263 POPLAR AVE
Provider Second Line Business Practice Location Address:
STE 1052
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38119-4736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-761-6157
Provider Business Practice Location Address Fax Number:
901-213-4513
Provider Enumeration Date:
07/29/2005

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: 207QG0300X , with the licence number:  MD15653 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080040881 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 2008944 . This is a "BLUECROSS&BLUESHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3017714 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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