1528251295 NPI number — SUZANNE JARVIS RPT

Table of content: SUZANNE JARVIS RPT (NPI 1528251295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528251295 NPI number — SUZANNE JARVIS RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JARVIS
Provider First Name:
SUZANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
F

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:
1528251295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1908 FLINT RD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35601-6031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-340-9708
Provider Business Mailing Address Fax Number:
256-340-9624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
674 OLLIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLANTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35045-2246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-280-1100
Provider Business Practice Location Address Fax Number:
205-280-1575
Provider Enumeration Date:
08/24/2007

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:  PTH1757 , 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: 1003819608 . This is a "GROUP NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-39340 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-39343 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-39344 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529917620 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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