1073730602 NPI number — JETT MEDICAL CO LLC

Table of content: (NPI 1073730602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073730602 NPI number — JETT MEDICAL CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JETT MEDICAL CO 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:
1073730602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43566
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35243-0566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-678-8807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 LAKE DR SE STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BESSEMER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35022-6488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-561-9572
Provider Business Practice Location Address Fax Number:
205-481-9345
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARGER
Authorized Official First Name:
DONNIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
205-481-9344

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  585 , 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: 51526611 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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