1629394705 NPI number — MERRI BETH GILLIAM CRNP, PC

Table of content: (NPI 1629394705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629394705 NPI number — MERRI BETH GILLIAM CRNP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRI BETH GILLIAM CRNP, 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:
1629394705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1735
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35612-6735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-233-0712
Provider Business Mailing Address Fax Number:
256-233-3535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 US HIGHWAY 31 S
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35611-3619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-233-0712
Provider Business Practice Location Address Fax Number:
256-233-3535
Provider Enumeration Date:
04/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GILLIAM
Authorized Official First Name:
MERRI
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
CRNP / OWNER
Authorized Official Telephone Number:
256-233-0712

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  1-073255 , 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: 891017564 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com