Provider Demographics
NPI:1568095503
Name:EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN
Entity Type:Organization
Organization Name:EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIALIST TECHNOLOGIST
Authorized Official - Prefix:PROF
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:650-253-0000
Mailing Address - Street 1:300 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7715
Mailing Address - Country:US
Mailing Address - Phone:650-253-0000
Mailing Address - Fax:650-253-0001
Practice Address - Street 1:229 PAOAKALANI AVE # 714
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-3764
Practice Address - Country:US
Practice Address - Phone:650-253-0000
Practice Address - Fax:650-253-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No251B00000XAgenciesCase Management
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No347D00000XTransportation ServicesTrain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS314125401722Medicaid