1922149798 NPI number — DR. LISA DYER YOUNG M.D.

Table of content: MELISSA BULAS-MERCURI PT DPT (NPI 1447619101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922149798 NPI number — DR. LISA DYER YOUNG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
LISA
Provider Middle Name:
DYER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DYER
Provider Other First Name:
LISA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922149798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 VILLAGE PROFESSIONAL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OPELIKA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36801-4702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-749-8121
Provider Business Mailing Address Fax Number:
334-749-6166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 VILLAGE PROFESSIONAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OPELIKA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36801-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-749-8121
Provider Business Practice Location Address Fax Number:
334-749-6166
Provider Enumeration Date:
02/12/2007

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: 208000000X , with the licence number:  21253 , 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: 21253 . This is a "ALABAMA CONTR SUBST CERT" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 36452 . This is a "AMERICAN BOARD PEDIATRICS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 510-96615 . This is a "BCBS AL PROV # AUBURN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 177521 . This is a "AAP ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21253 . This is a "ALABAMA MEDICAL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 510-96612 . This is a "BCBS AL PROV # OPELIKA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1210778 . This is a "UNITED HEALTH PROV #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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