1326116468 NPI number — UROLOGIC CLINICS OF NORTH ALABAMA P C

Table of content: (NPI 1326116468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326116468 NPI number — UROLOGIC CLINICS OF NORTH ALABAMA P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGIC CLINICS OF NORTH ALABAMA P C
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:
POPLAR BLUFF UROLOGY
Provider Other Organization Name Type Code:
3
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:
1326116468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 LUCY LEE PKWY STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-2427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-609-2266
Provider Business Mailing Address Fax Number:
573-785-0974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 LUCY LEE PKWY STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-2427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-609-2266
Provider Business Practice Location Address Fax Number:
573-785-0974
Provider Enumeration Date:
11/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAKRABARTY
Authorized Official First Name:
AMIT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
573-609-2266

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  2014002134 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000092909 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200018019 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG5071 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".