1205888013 NPI number — JEFFREY M MOLL M.D.

Table of content: JEFFREY M MOLL M.D. (NPI 1205888013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205888013 NPI number — JEFFREY M MOLL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLL
Provider First Name:
JEFFREY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1205888013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10824
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:
35202-0824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-322-1808
Provider Business Mailing Address Fax Number:
205-322-1851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W MORENO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32501-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-437-8390
Provider Business Practice Location Address Fax Number:
850-437-8394
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  ME88936 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 59169913 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00134527 . This is a "PALMETTO GBA-RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 82124 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59169914 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009982065 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268309100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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