1083832208 NPI number — RUSSELL PATRICK SARAULT III DPT

Table of content: RUSSELL PATRICK SARAULT III DPT (NPI 1083832208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083832208 NPI number — RUSSELL PATRICK SARAULT III DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SARAULT
Provider First Name:
RUSSELL
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1083832208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 CORPORATE DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOVER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35242-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-497-0005
Provider Business Mailing Address Fax Number:
215-629-5531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 E PULASKI HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21921-6430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-671-1119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2007

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: 225100000X , with the licence number:  PT018622 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 30032 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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