Provider Demographics
NPI:1942264023
Name:TRIPLETT, JEFFREY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:TRIPLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15055 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0001
Mailing Address - Country:US
Mailing Address - Phone:256-383-3325
Mailing Address - Fax:256-383-5911
Practice Address - Street 1:1514 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3248
Practice Address - Country:US
Practice Address - Phone:662-332-6150
Practice Address - Fax:662-332-4558
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN210072085R0001X
ARE12112085R0001X
MS237942085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621648477OtherFEDERAL TAX ID
TN3049015OtherBLUE CROSS BLUE SHIELD
AR131791001Medicaid
AR97476OtherBCBS ARKANSAS
MS0140200Medicaid
TNG40442Medicare UPIN
AR97476OtherBCBS ARKANSAS
ARG40442Medicare UPIN