1962677708 NPI number — MR. JASON LEE FOWLER P.T.

Table of content: MR. JASON LEE FOWLER P.T. (NPI 1962677708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962677708 NPI number — MR. JASON LEE FOWLER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLER
Provider First Name:
JASON
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1962677708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 CORPORATE DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOVER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35242-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3099 BRECKENRIDGE LN STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40220-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-963-5229
Provider Business Practice Location Address Fax Number:
502-963-5365
Provider Enumeration Date:
04/23/2008

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:  004150 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6464207 . This is a "CIGNA PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6830783 . This is a "UNITED HEALTHCARE PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100642510 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS2003600562 . This is a "CARESOURCE PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300033296 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000001332483 . This is a "ANTHEM PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2143551 . This is a "WELLCARE OF KY PROVIDER ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: PDZ000000455121 . This is a "AETNA BETTER HEALTH OF KY PROVIDER ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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