1245276112 NPI number — MIDSTATE MEDICAL SERVICE

Table of content: (NPI 1245276112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245276112 NPI number — MIDSTATE MEDICAL SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDSTATE MEDICAL SERVICE
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:
1245276112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36106-0070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-263-6034
Provider Business Mailing Address Fax Number:
334-264-2436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1507 MULBERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36106-1519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-263-6034
Provider Business Practice Location Address Fax Number:
334-264-2436
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHERRY
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-263-6034

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  0003497 , 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: 000051822 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: U98718 . This is a "AMERIHEALTH PROV. NUM." identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 304307 . This is a "COMBINED INS. CO. OF AMER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 4582366 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51051822MID . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0007965237 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: V16192 . This is a "VGM/HOMELINK PROV. NUM." identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 304307 . This is a "HEALTH INS. CORP. OF ALA." identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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