Basic Information
Provider Information | |||||||||
NPI: | 1831305572 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEPHEN D RAINES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STEPHEN D RAINES DPM | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 7318850216 | ||||||||
Practice Location | |||||||||
Address1: | 215 HAWKS RD | ||||||||
Address2: |   | ||||||||
City: | MARTIN | ||||||||
State: | TN | ||||||||
PostalCode: | 382372708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7315885191 | ||||||||
FaxNumber: | 7315885073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2007 | ||||||||
LastUpdateDate: | 06/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAINES | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7318850220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
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 | 1103090003 | 01 | TN | DME SUPPLIER | OTHER |