1972541209 NPI number — MRS. SHANNON R SCOGGINS P.T.

Table of content: MRS. SHANNON R SCOGGINS P.T. (NPI 1972541209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972541209 NPI number — MRS. SHANNON R SCOGGINS P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOGGINS
Provider First Name:
SHANNON
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
SHANNON
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972541209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 COOK STREET
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
MADISONVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-442-1440
Provider Business Mailing Address Fax Number:
423-442-1441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 COOK STREET
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MADISONVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-442-1440
Provider Business Practice Location Address Fax Number:
423-442-1441
Provider Enumeration Date:
06/02/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3156797 . This is a "BCBST - GROUP NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0446652 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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