Provider Demographics
NPI:1962534677
Name:STEPHEN D. RAINES
Entity type:Organization
Organization Name:STEPHEN D. RAINES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-885-0220
Mailing Address - Street 1:1415 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5812
Mailing Address - Country:US
Mailing Address - Phone:731-885-0220
Mailing Address - Fax:731-885-0216
Practice Address - Street 1:1901 COOK ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1882
Practice Address - Country:US
Practice Address - Phone:731-286-2139
Practice Address - Fax:731-286-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM 658213ES0103X
TNDPM217213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3350896Medicaid
TN1790999456OtherDME NPI
TN1548228620OtherNPI
TN3354277Medicaid
TN1568496172OtherNPI
TNT61077Medicare UPIN
TN3354277Medicare ID - Type Unspecified
TN3350896Medicare ID - Type Unspecified
TN3717524Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
TN1568496172OtherNPI
TNV10699Medicare UPIN