1801923362 NPI number — MR. JEFFERY ALLEN PHILLIPS BS, CSAC

Table of content: MR. JEFFERY ALLEN PHILLIPS BS, CSAC (NPI 1801923362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801923362 NPI number — MR. JEFFERY ALLEN PHILLIPS BS, CSAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
JEFFERY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS, CSAC
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:
1801923362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37615-9054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-467-3600
Provider Business Mailing Address Fax Number:
423-467-3644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RR 6 BOX 540
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GATE CITY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24251-9760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-452-1142
Provider Business Practice Location Address Fax Number:
276-452-1140
Provider Enumeration Date:
02/28/2007

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: 101Y00000X , with the licence number:  CSAC 0710101751 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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