Provider Demographics
NPI:1114105814
Name:STEPHEN D RAINES D.P.M.
Entity Type:Organization
Organization Name:STEPHEN D RAINES D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE 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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM217332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1962534677OtherDME
TN3350894Medicaid
TN3350894Medicaid