=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497918593
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CATHERINE VADIME NETCHVOLODOFF MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2008
-----------------------------------------------------
Last Update Date | 07/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 CORDER DR
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38834-6210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-284-9995
-----------------------------------------------------
Fax | 662-284-9920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 BERWYN DR
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72227-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-221-7087
-----------------------------------------------------
Fax | 662-284-9920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | R-4121
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------