1720042963 NPI number — BHC-BLOUNT & ETOWAH COUNTIES

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 1720042963 NPI number — BHC-BLOUNT & ETOWAH COUNTIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BHC-BLOUNT & ETOWAH COUNTIES
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:
BHC-ONEONTA
Provider Other Organization Name Type Code:
3
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:
1720042963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 830605
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:
35283-0605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-715-5943
Provider Business Mailing Address Fax Number:
205-715-5932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 GILBREATH DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ONEONTA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35121-2827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-274-8198
Provider Business Practice Location Address Fax Number:
205-274-8197
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FENN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
CHIEF INTEGRATION OFFICER
Authorized Official Telephone Number:
205-715-5415

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 541003873 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529301940 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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