1972090991 NPI number — HANNAHAN COMPREHENSIVE PAIN CARE PC

Table of content: (NPI 1972090991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972090991 NPI number — HANNAHAN COMPREHENSIVE PAIN CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANNAHAN COMPREHENSIVE PAIN CARE PC
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:
6
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:
1972090991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-1747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-417-0450
Provider Business Mailing Address Fax Number:
801-315-4946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 JAMES DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENTERPRISE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-599-6445
Provider Business Practice Location Address Fax Number:
801-315-4946
Provider Enumeration Date:
04/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HANNAHAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
334-417-0450

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  20671 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000060068 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111211800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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