1013577634 NPI number — ENT CENTER OF NORTHWEST ALABAMA, LLC

Table of content: RUSSELL DYLAN PURPURA MD (NPI 1083144588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013577634 NPI number — ENT CENTER OF NORTHWEST ALABAMA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENT CENTER OF NORTHWEST ALABAMA, LLC
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:
1013577634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1949 FLORENCE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35630-2729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-986-6734
Provider Business Mailing Address Fax Number:
256-768-9187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1949 FLORENCE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35630-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-986-6734
Provider Business Practice Location Address Fax Number:
256-768-9187
Provider Enumeration Date:
06/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MASTERSON
Authorized Official First Name:
CALEB
Authorized Official Middle Name:
GERALD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-986-6734

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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