1124105671 NPI number — SHOALS EAR NOSE & THROAT GROUP PC

Table of content: (NPI 1124105671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124105671 NPI number — SHOALS EAR NOSE & THROAT GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOALS EAR NOSE & THROAT GROUP PC
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:
F ALLEN LONG MD
Provider Other Organization Name Type Code:
5
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:
1124105671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 COX BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEFFIELD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-386-7040
Provider Business Mailing Address Fax Number:
256-383-7808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 COX BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEFFIELD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-386-7040
Provider Business Practice Location Address Fax Number:
256-383-7808
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
256-386-7040

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  10880 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51011662 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com