1093939894 NPI number — MOUNTAIN BROOK PLASTIC SURGERY AND LASER CENTER

Table of content: (NPI 1093939894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093939894 NPI number — MOUNTAIN BROOK PLASTIC SURGERY AND LASER CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN BROOK PLASTIC SURGERY AND LASER CENTER
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:
1093939894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 CAHABA RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35223-2346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-871-4440
Provider Business Mailing Address Fax Number:
205-871-7776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 CAHABA RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35223-2346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-871-4440
Provider Business Practice Location Address Fax Number:
205-871-7776
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIVES
Authorized Official First Name:
LAUREN
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL MANAGER
Authorized Official Telephone Number:
205-871-4440

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  AL16730 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1310014 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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