1972794394 NPI number — TAMEKA STACEY-ANN FUNNY D.O.

Table of content: TAMEKA STACEY-ANN FUNNY D.O. (NPI 1972794394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972794394 NPI number — TAMEKA STACEY-ANN FUNNY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNNY
Provider First Name:
TAMEKA
Provider Middle Name:
STACEY-ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMPSON
Provider Other First Name:
TAMEKA
Provider Other Middle Name:
STACEY-ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972794394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-7303
Provider Business Mailing Address Fax Number:
803-296-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 TAYLOR ST
Provider Second Line Business Practice Location Address:
SUITE 6F
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-296-3273
Provider Business Practice Location Address Fax Number:
803-296-7061
Provider Enumeration Date:
08/09/2007

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: 207RI0200X , with the licence number:  39903 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0200X , with the licence number: OS11222 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 14FV3 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 399037 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004076000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com