Basic Information
Provider Information | |||||||||
NPI: | 1942264023 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRIPLETT | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15055 COLLECTION CENTER DR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606930001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563833325 | ||||||||
FaxNumber: | 2563835911 | ||||||||
Practice Location | |||||||||
Address1: | 1514 E UNION ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387033248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623326150 | ||||||||
FaxNumber: | 6623324558 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 02/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 21007 | TN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | E1211 | AR | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 23794 | MS | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 621648477 | 01 | TN | FEDERAL TAX ID | OTHER | 3049015 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 131791001 | 05 | AR |   | MEDICAID | 97476 | 01 | AR | BCBS ARKANSAS | OTHER | 0140200 | 05 | MS |   | MEDICAID |