1841635281 NPI number — MR. STEVEN DOUGLAS TATUM FNP

Table of content: MADISON PAIGE FISCHER (NPI 1407619182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841635281 NPI number — MR. STEVEN DOUGLAS TATUM FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATUM
Provider First Name:
STEVEN
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1841635281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 N STATE OF FRANKLIN RD
Provider Second Line Business Mailing Address:
SUITE 24
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-6089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-431-1810
Provider Business Mailing Address Fax Number:
423-431-1811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 N STATE OF FRANKLIN RD
Provider Second Line Business Practice Location Address:
SUITE 24
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-6089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-431-1810
Provider Business Practice Location Address Fax Number:
423-431-1811
Provider Enumeration Date:
04/29/2013

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: 363LF0000X , with the licence number:  0000017566 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024171753 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1841635281 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q005478 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01505489 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100305530 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1841635281 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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