Healthcare Provider Details

I. General information

NPI: 1962534677
Provider Name (Legal Business Name): STEPHEN D. RAINES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 COOK ST
DYERSBURG TN
38024-1882
US

IV. Provider business mailing address

1415 E REELFOOT AVE
UNION CITY TN
38261-5812
US

V. Phone/Fax

Practice location:
  • Phone: 731-286-2139
  • Fax: 731-286-2201
Mailing address:
  • Phone: 731-885-0220
  • Fax: 731-885-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM 658
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDPM217
License Number StateTN

VIII. Authorized Official

Name: MRS. NANCY W. RAINES
Title or Position: OFFICE MANAGER
Credential:
Phone: 731-885-0220