1679723241 NPI number — CRYSTAL L DILLARD PHD

Table of content: CRYSTAL L DILLARD PHD (NPI 1679723241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679723241 NPI number — CRYSTAL L DILLARD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLARD
Provider First Name:
CRYSTAL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1679723241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11407 DRAWER 1492
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:
35246-1492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-939-9193
Provider Business Mailing Address Fax Number:
205-939-9949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 7TH AVE S
Provider Second Line Business Practice Location Address:
ACC 500
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:
205-939-9193
Provider Business Practice Location Address Fax Number:
205-939-9949
Provider Enumeration Date:
09/19/2008

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: 103T00000X , with the licence number:  1545 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 1545 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 2829 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 515-97317 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-98119 . This is a "FEDERAL BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1679723241 . This is a "TRICARE SOUTH" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-97316 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-98120 . This is a "FEDERAL BC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 109018 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109021 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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