1104653062 NPI number — DERMA BIRMINGHAM LLC

Table of content: (NPI 1104653062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104653062 NPI number — DERMA BIRMINGHAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMA BIRMINGHAM 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:
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:
1104653062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2142 TYLER RD STE 110
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:
35226-1307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-825-5575
Provider Business Mailing Address Fax Number:
205-825-5576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2142 TYLER RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOOVER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35226-1307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-825-5575
Provider Business Practice Location Address Fax Number:
205-825-5576
Provider Enumeration Date:
09/16/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HUNT
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
MARCHIONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
205-825-5575

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 341871 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104653062 . This is a "NPI GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1477932192 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 237277 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 342122 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".