Basic Information
Provider Information | |||||||||
NPI: | 1669642096 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAINER | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.R.N.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1421 N STATE ST | ||||||||
Address2: | SUITE 203 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392021658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013551234 | ||||||||
FaxNumber: | 6013263537 | ||||||||
Practice Location | |||||||||
Address1: | 1815 MISSION 66 | ||||||||
Address2: |   | ||||||||
City: | VICKSBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 391803709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016388801 | ||||||||
FaxNumber: | 6013263537 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/29/2008 | ||||||||
LastUpdateDate: | 01/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R503886 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 04833363 | 05 | MS |   | MEDICAID |