1932153624 NPI number — MRS. MELANIE RUTH WORTMAN

Table of content: MRS. MELANIE RUTH WORTMAN (NPI 1932153624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932153624 NPI number — MRS. MELANIE RUTH WORTMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WORTMAN
Provider First Name:
MELANIE
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1932153624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 DIXIE LEE CENTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIMBALL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37347-5672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-837-7536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501A WESTFIELD PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37347-5144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-942-3009
Provider Business Practice Location Address Fax Number:
423-942-3099
Provider Enumeration Date:
05/19/2006

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: 225100000X , with the licence number:  2319 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT0000002319 , 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: 62-1407143 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 3110918 . This is a "BLUECROSS BLUESHIELD OF T" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 621407143 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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