1114021409 NPI number — OBSTETRICS & GYNECOLOGY OF DOTHAN INC

Table of content: (NPI 1114021409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114021409 NPI number — OBSTETRICS & GYNECOLOGY OF DOTHAN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OBSTETRICS & GYNECOLOGY OF DOTHAN INC
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:
1114021409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-671-9445
Provider Business Mailing Address Fax Number:
334-836-0059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-671-9445
Provider Business Practice Location Address Fax Number:
334-836-0059
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAYLORD
Authorized Official First Name:
DANA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
334-671-9445

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  23245 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 26014 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: DO1161 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 31759 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 31756 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 32437 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA-204 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LX0001X , with the licence number: 1006758 , 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: 01D2068157 . This is a "CLIA WAVIER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01D0989955 . This is a "CLIA WAIVED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1826 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: C47766 . This is a "MEDICAL PROTECTIVE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 529928670 . This is a "MEDICAID GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01D2043043 . This is a "CLIA WAIVED" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051502953 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01D2052896 . This is a "CLIA WAIVED" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 01D2074304 . This is a "CLIA WAIVED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 051520983 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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