Basic Information
Provider Information | |||||||||
NPI: | 1114105814 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEPHEN D RAINES D.P.M. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1415 E REELFOOT AVE | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 382615812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7318850220 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1901 COOK ST | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380241882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312862139 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2008 | ||||||||
LastUpdateDate: | 02/05/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAINES | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7318850220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | DPM217 | TN | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 1962534677 | 01 | TN | DME | OTHER | 3350894 | 05 | TN |   | MEDICAID |