1922064047 NPI number — DR. JACK H WHITAKER MD

Table of content: DR. JACK H WHITAKER MD (NPI 1922064047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922064047 NPI number — DR. JACK H WHITAKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITAKER
Provider First Name:
JACK
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1922064047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 W STONE DR
Provider Second Line Business Mailing Address:
SUITE 6A
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-408-7220
Provider Business Mailing Address Fax Number:
423-408-7405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 TUSCULUM BLVD.,
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
GREENEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-638-2270
Provider Business Practice Location Address Fax Number:
423-928-0219
Provider Enumeration Date:
04/26/2006

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: 207RC0000X , with the licence number:  0101245897 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 20931 , 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: TN01S2 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4082722 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3078282 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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