Basic Information
| Provider Information | |||||||||
| NPI: | 1962534677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHEN D. RAINES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RAINES FOOT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 E REELFOOT AVE | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382615812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318850220 | ||||||||
| FaxNumber: | 7318850216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 COOK ST | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380241882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312862139 | ||||||||
| FaxNumber: | 7312862201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 11/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAINES | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7318850220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | DPM 658 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | DPM217 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3350896 | 05 | TN | MEDICAID | 1790999456 | 01 | TN | DME NPI | OTHER | 1548228620 | 01 | TN | NPI | OTHER | 3354277 | 05 | TN | MEDICAID | 1568496172 | 01 | TN | NPI | OTHER |