Healthcare Provider Details

I. General information

NPI: 1568095503
Provider Name (Legal Business Name): EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 11/27/2023
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 PAOAKALANI AVE # 714
HONOLULU HI
96815-3764
US

IV. Provider business mailing address

300 FAIRWAY DR
HATTIESBURG MS
39401-7715
US

V. Phone/Fax

Practice location:
  • Phone: 650-253-0000
  • Fax: 650-253-0001
Mailing address:
  • Phone: 650-253-0000
  • Fax: 650-253-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332100000X
TaxonomyDepartment of Veterans Affairs (VA) Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347D00000X
TaxonomyTrain
License Number
License Number State

VIII. Authorized Official

Name: PROF. JACOB CORNELIUS PARKER
Title or Position: SPECIALIST TECHNOLOGIST
Credential: DO
Phone: 650-253-0000