1063457919 NPI number — BAY AREA ORAL SURGERY PC

Table of content: (NPI 1063457919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063457919 NPI number — BAY AREA ORAL SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY AREA ORAL SURGERY PC
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:
1063457919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5901 GRELOT RD
Provider Second Line Business Mailing Address:
BUILDING C
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36609-3603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-344-6191
Provider Business Mailing Address Fax Number:
251-344-6794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 GRELOT RD
Provider Second Line Business Practice Location Address:
BUILDING C
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36609-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-344-6191
Provider Business Practice Location Address Fax Number:
251-344-6794
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARZULLO
Authorized Official First Name:
JEANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
251-344-6191

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  3814 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 4598 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 5437 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000090524 . This is a "BCBS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 257083 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1021853899 . This is a "MEDICARE PTAN SHEPPARD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000005454 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0000094869 . This is a "BCBS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0000032729 . This is a "BCBS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 165624 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 167941 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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