1902929532 NPI number — LIBBY P MASSIE APN

Table of content: LIBBY P MASSIE APN (NPI 1902929532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902929532 NPI number — LIBBY P MASSIE APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSIE
Provider First Name:
LIBBY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1902929532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 BROOKSIDE DR
Provider Second Line Business Mailing Address:
THIRD FLOOR
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-857-5907
Provider Business Mailing Address Fax Number:
423-857-5904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 BROOKSIDE DR
Provider Second Line Business Practice Location Address:
THIRD FLOOR
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-857-5907
Provider Business Practice Location Address Fax Number:
423-857-5904
Provider Enumeration Date:
04/09/2007

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: 363L00000X , with the licence number:  12660 , 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: 3341119 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q002696 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902929532 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00844330 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7000630 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100112430 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00844325 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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