1538347562 NPI number — MS. LORISSIA RENEA AUTERY M.D.

Table of content: MS. LORISSIA RENEA AUTERY M.D. (NPI 1538347562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538347562 NPI number — MS. LORISSIA RENEA AUTERY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUTERY
Provider First Name:
LORISSIA
Provider Middle Name:
RENEA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1538347562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 HIGHWAY 78 E
Provider Second Line Business Mailing Address:
SUITE 504
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35501-8907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-384-0011
Provider Business Mailing Address Fax Number:
205-384-4538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 BLACKWELL DAIRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35504-8406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-384-4801
Provider Business Practice Location Address Fax Number:
205-384-4538
Provider Enumeration Date:
01/31/2008

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: 207V00000X , with the licence number:  31072 , 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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