1104990415 NPI number — LISENBY PODIATRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104990415 NPI number — LISENBY PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISENBY PODIATRY
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:
Provider Other Organization Name Type Code:
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:
1104990415
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-671-1441
Provider Business Mailing Address Fax Number:
334-671-1688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-671-1441
Provider Business Practice Location Address Fax Number:
334-671-1688
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LISENBY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
HARRISON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-671-1441

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  144 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 511 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000074869 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74869 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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