1194711382 NPI number — DR. CHARLES VANCE BUCKMASTER M.D.

Table of content: DR. CHARLES VANCE BUCKMASTER M.D. (NPI 1194711382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194711382 NPI number — DR. CHARLES VANCE BUCKMASTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKMASTER
Provider First Name:
CHARLES
Provider Middle Name:
VANCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUCKMASTER
Provider Other First Name:
CHARLES
Provider Other Middle Name:
VANCE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194711382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8158 STATE HWY 59, SUITE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLEY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-955-1600
Provider Business Mailing Address Fax Number:
251-943-7749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8158 STATE HIGHWAY 59
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
FOLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36535-3880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-955-1600
Provider Business Practice Location Address Fax Number:
251-955-1602
Provider Enumeration Date:
09/22/2005

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: 208D00000X , with the licence number:  00020768 , 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: 170120 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00032604 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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