1962789305 NPI number — MRS. TARA UNDERWOOD MUDD MSN, APRN, NP-C

Table of content: MRS. TARA UNDERWOOD MUDD MSN, APRN, NP-C (NPI 1962789305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962789305 NPI number — MRS. TARA UNDERWOOD MUDD MSN, APRN, NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUDD
Provider First Name:
TARA
Provider Middle Name:
UNDERWOOD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, APRN, NP-C
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:
1962789305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6420 DUTCHMANS PKWY
Provider Second Line Business Practice Location Address:
HEART RHYTHM CENTER
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40205-3372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-891-8400
Provider Business Practice Location Address Fax Number:
502-891-8401
Provider Enumeration Date:
11/14/2011

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:  3007194 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2200X , with the licence number: 3007194 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 201065430 . This is a "MEDICAID - NCVA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100192180 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50036576 . This is a "PASSPORT - NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000747133 . This is a "ANTHEM - CTS/NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 131915 . This is a "SIHO-CTS/NCVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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