1922030113 NPI number — GADSDEN REGIONAL PRIMARY CARE LLC

Table of content: (NPI 1922030113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922030113 NPI number — GADSDEN REGIONAL PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GADSDEN REGIONAL PRIMARY CARE LLC
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:
RUIZ NEUROSURGERY CLINIC, PC
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:
1922030113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 COMMERCE WAY
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
GADSDEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35903-1157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-494-3033
Provider Business Practice Location Address Fax Number:
256-494-3036
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7626

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  11698 , 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: 051515965 . This is a "BLUE CROSS BLUE SHIELD AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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