1427143015 NPI number — DR. BRIAN JEFFERY WIATRAK M.D.

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 1427143015 NPI number — DR. BRIAN JEFFERY WIATRAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIATRAK
Provider First Name:
BRIAN
Provider Middle Name:
JEFFERY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIATRAK
Provider Other First Name:
BRIAN
Provider Other Middle Name:
JEFFERY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1427143015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4931 COLD HARBOR DRIVE
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:
35223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-951-5488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 ELMER J. BISSELL ROAD
Provider Second Line Business Practice Location Address:
PEDIATRIC ENT ASSOCIATES
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-638-4949
Provider Business Practice Location Address Fax Number:
205-638-4983
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207YP0228X , with the licence number:  17153 , 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: 2322124 . This is a "CIGNA HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1205935012 . This is a "HOSPITAL NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000045535 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 63030730626 . This is a "CHILDRENS HOSPITAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 63030730629 . This is a "CHILDRENS SOUTH" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1010005 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 25457 . This is a "SOUTHERN HEALTH SYSTEMS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529903800 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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