1821204108 NPI number — NATCHEZ THORACIC,VASCULAR AND SURGERY CLINIC

Table of content: (NPI 1821204108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821204108 NPI number — NATCHEZ THORACIC,VASCULAR AND SURGERY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATCHEZ THORACIC,VASCULAR AND SURGERY CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1821204108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70898-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-924-9827
Provider Business Mailing Address Fax Number:
225-924-9829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 SERGEANT PRENTISS DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
NATCHEZ
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39120-4792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-446-6068
Provider Business Practice Location Address Fax Number:
601-446-9990
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUBENSTEIN
Authorized Official First Name:
FORREST
Authorized Official Middle Name:
SCOT
Authorized Official Title or Position:
SURGEON
Authorized Official Telephone Number:
601-446-6068

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  19606 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1548281926 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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