1992997415 NPI number — TONYA D SHANAHAN

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 1992997415 NPI number — TONYA D SHANAHAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANAHAN
Provider First Name:
TONYA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1992997415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35403-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-614-6102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2731 MLK JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-5235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-349-3250
Provider Business Practice Location Address Fax Number:
205-345-3993
Provider Enumeration Date:
08/17/2007

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: 363LF0000X , with the licence number:  1082093 , 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: 104109 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 515-93760 . This is a "BCBS/AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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