1720102387 NPI number — DRS. KETCHAM AND DISMUKES

Table of content: (NPI 1720102387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720102387 NPI number — DRS. KETCHAM AND DISMUKES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS. KETCHAM AND DISMUKES
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:
1720102387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 HWY 80 E
Provider Second Line Business Mailing Address:
P.O. BOX 650
Provider Business Mailing Address City Name:
DEMOPOLIS
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-289-0499
Provider Business Mailing Address Fax Number:
334-289-3013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 HWY 80 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMOPOLIS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-289-0499
Provider Business Practice Location Address Fax Number:
334-289-3013
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAYTON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
SMITH
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
334-289-0499

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2802 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000088680 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0110356 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000088681 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0110247 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051088680 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051088681 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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