1831173707 NPI number — DR. WALLACE EDMONDSON TAYLOR JR. M.D.

Table of content: DR. WALLACE EDMONDSON TAYLOR JR. M.D. (NPI 1831173707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831173707 NPI number — DR. WALLACE EDMONDSON TAYLOR JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
WALLACE
Provider Middle Name:
EDMONDSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1831173707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 BEARDSLEY LN
Provider Second Line Business Mailing Address:
SUITE D-101
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78746-4945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-338-9840
Provider Business Mailing Address Fax Number:
512-338-0863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 BEARDSLEY LN
Provider Second Line Business Practice Location Address:
SUITE D-101
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746-4945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-338-9840
Provider Business Practice Location Address Fax Number:
512-338-0863
Provider Enumeration Date:
12/02/2005

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: 207Y00000X , with the licence number:  28006 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01280064 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00209209 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: TA37805 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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