1730230061 NPI number — BHC-MARTIN DERMATOLOGY AND SKIN WELLNESS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730230061 NPI number — BHC-MARTIN DERMATOLOGY AND SKIN WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BHC-MARTIN DERMATOLOGY AND SKIN WELLNESS
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:
1730230061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3201 4TH AVE S
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:
35222-1723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-715-5943
Provider Business Mailing Address Fax Number:
205-715-5932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5295 PRESERVE PKWY
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
HOOVER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35244-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-682-8022
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FENN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-715-5415

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DF4941 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 529931870 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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