1104865021 NPI number — THE CENTER FOR COLON AND DIGESTIVE DISEASE P C

Table of content: (NPI 1104865021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104865021 NPI number — THE CENTER FOR COLON AND DIGESTIVE DISEASE P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CENTER FOR COLON AND DIGESTIVE DISEASE P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE COLON AND DIGESTIVE DISEASE CENTER P C
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104865021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2324
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35201-2324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-533-7064
Provider Business Mailing Address Fax Number:
256-704-0115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 LONGWOOD DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-533-6488
Provider Business Practice Location Address Fax Number:
256-533-6495
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-533-6488

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4400135 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL0068 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529102520 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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