1710054556 NPI number — DEEP SOUTH DERMATOLOGY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710054556 NPI number — DEEP SOUTH DERMATOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEEP SOUTH DERMATOLOGY
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:
1710054556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAPHNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36526-0040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-621-2244
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8573 COUNTY ROAD 64
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAPHNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36526-8706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-621-2244
Provider Business Practice Location Address Fax Number:
251-621-7209
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STANFORD
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
251-621-2244

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  00018113 , 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: 30930 . This is a "AL BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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