1518934140 NPI number — MR. CAREY WAYNE KETCHUM MD

Table of content: MR. CAREY WAYNE KETCHUM MD (NPI 1518934140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518934140 NPI number — MR. CAREY WAYNE KETCHUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHUM
Provider First Name:
CAREY
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KETCHUM
Provider Other First Name:
CAREY
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1518934140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2147 RIVERCHASE OFFICE RD
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:
35244-1836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-403-8902
Provider Business Mailing Address Fax Number:
205-982-0278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1664 FORESTDALE BLVD
Provider Second Line Business Practice Location Address:
AMERICAN FAMILY CARE INC FORESTDALE CLINIC
Provider Business Practice Location Address City Name:
FORESTDALE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-791-2273
Provider Business Practice Location Address Fax Number:
205-791-9753
Provider Enumeration Date:
03/02/2006

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: 207R00000X , with the licence number:  10232 , 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: 51590263 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00155440 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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