1932249075 NPI number — MEDISTAT, INC

Table of content: (NPI 1932249075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932249075 NPI number — MEDISTAT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDISTAT, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1932249075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38308-0112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-660-0060
Provider Business Mailing Address Fax Number:
731-660-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
935 OLD HUMBOLDT RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38305-9625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-660-0060
Provider Business Practice Location Address Fax Number:
731-660-0622
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
731-660-0060

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0000000806 , 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: 104735 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3558573 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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