1639112329 NPI number — MICHAEL J CONKLIN MD

Table of content: MICHAEL J CONKLIN MD (NPI 1639112329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639112329 NPI number — MICHAEL J CONKLIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONKLIN
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
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:
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:
1639112329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 7TH AVE S
Provider Second Line Business Mailing Address:
LOWDER 316
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35233-1711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-638-9146
Provider Business Mailing Address Fax Number:
205-638-9833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 7TH AVE S
Provider Second Line Business Practice Location Address:
LOWDER 316
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35233-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-638-9146
Provider Business Practice Location Address Fax Number:
205-638-9833
Provider Enumeration Date:
06/13/2006

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: 207X00000X , with the licence number:  17564 , 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: 000085351 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009996775 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0123411 . This is a "MISSISSIPPI MEDICAID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: F64351 . This is a "VIVA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000085351 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 110723997A . This is a "GEORGIA MEDICAID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009932087 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051528498 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: F64351 . This is a "HEALTHSPRING" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051529348 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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