1104859123 NPI number — EASTERN HOSPITAL MEDICINE PC

Table of content: (NPI 1104859123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104859123 NPI number — EASTERN HOSPITAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN HOSPITAL MEDICINE PC
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:
1104859123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 830674
Provider Second Line Business Mailing Address:
MSC#716
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35283-0674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-874-8300
Provider Business Mailing Address Fax Number:
205-874-8333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 MEDICAL PARK EAST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-838-3000
Provider Business Practice Location Address Fax Number:
205-874-8333
Provider Enumeration Date:
07/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WIMBERLY
Authorized Official First Name:
LEE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
205-874-8300

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DF1683 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 529930180 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".