1073605762 NPI number — LAUDERDALE RADIOLOGY GROUP

Table of content: (NPI 1073605762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073605762 NPI number — LAUDERDALE RADIOLOGY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUDERDALE RADIOLOGY GROUP
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:
1073605762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 S COURT STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-768-8168
Provider Business Mailing Address Fax Number:
256-768-8322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 VETERANS DRIVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-768-8168
Provider Business Practice Location Address Fax Number:
256-768-8322
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VONHERRMANN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
RADIOLOGIST
Authorized Official Telephone Number:
256-768-8168

Provider Taxonomy Codes

  • Taxonomy code: 247100000X , with the licence number:  00006072 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 247100000X , with the licence number: D0137 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X , with the licence number: 00023957 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X , with the licence number: 00016553 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X , with the licence number: MD.26676 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 51519728 . This is a "BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009934433 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51540375 . This is a "BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51039506 . This is a "BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009934439 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 528202620 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009934437 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51039286 . This is a "BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009934434 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51507878 . This is a "BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51543162 . This is a "BC EAST BILYEU" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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