1396738944 NPI number — MAXWELL AFB AMBULATORY HEALTH CARE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396738944 NPI number — MAXWELL AFB AMBULATORY HEALTH CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXWELL AFB AMBULATORY HEALTH CARE CENTER
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:
1396738944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 ASHTON PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLBROOK
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-290-0399
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S. TWINING STREET
Provider Second Line Business Practice Location Address:
BLDG 760, FAMILY PRACTICE - YELLOW TEAM
Provider Business Practice Location Address City Name:
MAXWELL AFB
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-953-2234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
TOMEKA
Authorized Official Middle Name:
DANIELLE
Authorized Official Title or Position:
FAMILY PRACTICE PHYSICIAN
Authorized Official Telephone Number:
334-953-1307

Provider Taxonomy Codes

  • Taxonomy code: 261QM1100X , with the licence number:  25934 , 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)





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