1982806352 NPI number — MCDONOUGH OBGYN

Table of content: (NPI 1982806352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982806352 NPI number — MCDONOUGH OBGYN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCDONOUGH OBGYN
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:
1982806352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 E WATTS ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ENTERPRISE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36330-1801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-347-4646
Provider Business Mailing Address Fax Number:
334-347-8719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 E WATTS ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ENTERPRISE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36330-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-347-4646
Provider Business Practice Location Address Fax Number:
334-347-8719
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONOUGH
Authorized Official First Name:
GILBERT
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
334-347-4646

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  3908 , 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: 04173 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1023077013 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 510-04173 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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