Basic Information
Provider Information | |||||||||
NPI: | 1528354768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NGIDO | ||||||||
FirstName: | FABIAN | ||||||||
MiddleName: | PHILEMON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 140 W 7TH ST | ||||||||
Address2: |   | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385011726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317835582 | ||||||||
FaxNumber: | 9315266760 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL CENTER BLVD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385014294 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317832770 | ||||||||
FaxNumber: | 9315251176 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2011 | ||||||||
LastUpdateDate: | 05/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 51472 | TN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7100423680 | 05 | KY |   | MEDICAID | Q006501 | 05 | TN |   | MEDICAID | 6017806 | 01 | TN | BCBS | OTHER |