1306818869 NPI number — EASTERN SHORE NEUROLOGY AND PAIN CLINIC

Table of content: (NPI 1306818869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306818869 NPI number — EASTERN SHORE NEUROLOGY AND PAIN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN SHORE NEUROLOGY AND PAIN CLINIC
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:
6
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:
1306818869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 W PEACHTREE AVE
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:
36535-2239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-971-3030
Provider Business Mailing Address Fax Number:
251-971-3035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 W PEACHTREE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36535-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-971-3030
Provider Business Practice Location Address Fax Number:
251-971-3035
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TARABEIN
Authorized Official First Name:
RASSAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
251-971-3030

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  AL18124 , 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: J619 . This is a "MEDICARE GROUP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0510348 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51034929 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 5940140 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0510010 . This is a "UNITED HAELTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51506401 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00033163 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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