1386814457 NPI number — KETURAH CRAIG DPM

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386814457 NPI number — KETURAH CRAIG DPM

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CRAIG

Provider First Name:

KETURAH

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DPM

Provider Gender Code:

F

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:

1386814457

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/30/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 661495

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BIRMINGHAM

Provider Business Mailing Address State Name:

AL

Provider Business Mailing Address Postal Code:

35266-1495

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

205-979-5882

Provider Business Mailing Address Fax Number:

205-979-1248

Provider First Line Business Practice Location Address:

507 S MAIN ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LINDEN

Provider Business Practice Location Address State Name:

AL

Provider Business Practice Location Address Postal Code:

36748-2025

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

334-578-2357

Provider Business Practice Location Address Fax Number:

334-295-5596

Provider Enumeration Date:

03/05/2008

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 213E00000X , with the licence number:  291 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1386814457 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 113458 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 113459 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 515-47487 . This is a "BC BS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 515-47481 . This is a "BC BS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 515-47484 . This is a "BC BS OFAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 510-49800 . This is a "BC BS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 510-49801 . This is a "BC BS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 6931751 . This is a "CIGNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 9509124 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 113460 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 510-49799 . This is a "BC BS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".