1518120385 NPI number — MRS. TAMATHA SULLIVAN DAVIDSON MCD CCCA

Table of content: MRS. TAMATHA SULLIVAN DAVIDSON MCD CCCA (NPI 1518120385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518120385 NPI number — MRS. TAMATHA SULLIVAN DAVIDSON MCD CCCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN DAVIDSON
Provider First Name:
TAMATHA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MCD CCCA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIDSON
Provider Other First Name:
TAMATHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1518120385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
188 HOSPITAL DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
FAIRHOPE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36532-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-928-0300
Provider Business Mailing Address Fax Number:
251-990-1898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 HOSPITAL DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
FAIRHOPE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36532-2038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-928-0300
Provider Business Practice Location Address Fax Number:
251-990-1898
Provider Enumeration Date:
07/02/2008

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: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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