1700093986 NPI number — EAR, NOSE, AND THROAT CLINIC, P.A.

Table of content: (NPI 1700093986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700093986 NPI number — EAR, NOSE, AND THROAT CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR, NOSE, AND THROAT CLINIC, P.A.
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:
1700093986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
652 LOMB AVE SW
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:
35211-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-787-1457
Provider Business Mailing Address Fax Number:
205-788-0073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
652 LOMB AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35211-1330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-787-1457
Provider Business Practice Location Address Fax Number:
205-788-0073
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DABBS
Authorized Official First Name:
JACK
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-787-1457

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD2799 , 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: D948 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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