1265584296 NPI number — DR. THOMAS DAVID UNDERHILL D.C.

Table of content: DR. THOMAS DAVID UNDERHILL D.C. (NPI 1265584296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265584296 NPI number — DR. THOMAS DAVID UNDERHILL D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERHILL
Provider First Name:
THOMAS
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1265584296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72811-0600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-967-4030
Provider Business Mailing Address Fax Number:
479-967-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2803 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-967-4030
Provider Business Practice Location Address Fax Number:
479-967-3713
Provider Enumeration Date:
01/18/2007

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: 111N00000X , with the licence number:  1242 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 71069775950 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 134606718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 653126 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 7366212 . This is a "AETNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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