1821504598 NPI number — CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC

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 1821504598 NPI number — CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC
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:
6
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:
1821504598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35544-0038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-606-1200
Provider Business Mailing Address Fax Number:
205-606-1202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12815 US HWY 278
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-606-1200
Provider Business Practice Location Address Fax Number:
205-606-1202
Provider Enumeration Date:
12/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
RUBLEY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER / PROVIDER
Authorized Official Telephone Number:
205-606-1200

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1-081378 , 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)





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