Healthcare Provider Details

I. General information

NPI: 1174970909
Provider Name (Legal Business Name): WHITAKER NATIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 JETT DR
JACKSON KY
41339
US

IV. Provider business mailing address

PO BOX 936434
ATLANTA GA
31193-6434
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-6000
  • Fax:
Mailing address:
  • Phone: 800-377-8721
  • Fax: 304-697-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MOORE
Title or Position: CFO
Credential:
Phone: 800-242-6711