1063575363 NPI number — CYRIAC MADATHIKUNNEL, MD, LLC

Table of content: (NPI 1063575363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063575363 NPI number — CYRIAC MADATHIKUNNEL, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYRIAC MADATHIKUNNEL, MD, 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:
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:
1063575363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 MEDICAL CENTER PKWY
Provider Second Line Business Mailing Address:
FRIST HOWELL BUILDING # 3
Provider Business Mailing Address City Name:
SELMA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36701-6742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-872-3339
Provider Business Mailing Address Fax Number:
334-872-6200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 MEDICAL CENTER PKWY
Provider Second Line Business Practice Location Address:
FRIST HOWELL BUILDING # 3
Provider Business Practice Location Address City Name:
SELMA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36701-6742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-872-3339
Provider Business Practice Location Address Fax Number:
334-872-6200
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MADATHIKUNNEL
Authorized Official First Name:
NIRMALA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
334-872-3339

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  00019370 , 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: 529914120 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51514539 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com