1588787220 NPI number — SURGICAL ONCOLOGY & GENERAL SUGERY, PC

Table of content: (NPI 1588787220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588787220 NPI number — SURGICAL ONCOLOGY & GENERAL SUGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL ONCOLOGY & GENERAL SUGERY, PC
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:
1588787220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-1195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-368-9826
Provider Business Mailing Address Fax Number:
251-368-3917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATMORE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36502-3016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-368-9826
Provider Business Practice Location Address Fax Number:
251-368-3917
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
251-368-9826

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  9132 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000080702 . This is a "MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 010024215 . This is a "RR MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51080702 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000080702 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529301280 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 008096900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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