1437395506 NPI number — MRS. MARY JANA CARROLL PT

Table of content: MRS. MARY JANA CARROLL PT (NPI 1437395506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437395506 NPI number — MRS. MARY JANA CARROLL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
MARY
Provider Middle Name:
JANA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARROLL
Provider Other First Name:
JANA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1437395506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2048A S BROAD ST
Provider Second Line Business Mailing Address:
BROOKLEY COMPLEX
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36615-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-433-1414
Provider Business Mailing Address Fax Number:
251-433-9634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2048A S BROAD ST
Provider Second Line Business Practice Location Address:
BROOKLEY COMPLEX
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36615-1285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-433-1414
Provider Business Practice Location Address Fax Number:
251-433-9634
Provider Enumeration Date:
12/19/2008

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: 225100000X , with the licence number:  2105 , 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: 51048200 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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