1134588734 NPI number — UNIVERSITY OF SOUTH ALABAMA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134588734 NPI number — UNIVERSITY OF SOUTH ALABAMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF SOUTH ALABAMA
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:
1134588734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40480
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36640-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-434-3626
Provider Business Mailing Address Fax Number:
251-445-2464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 MONTLIMAR DR
Provider Second Line Business Practice Location Address:
STE A-210
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36609-1713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-460-7189
Provider Business Practice Location Address Fax Number:
251-460-6369
Provider Enumeration Date:
02/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
IKNER
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSO ADMIN OF AMBULATORY CLINICS
Authorized Official Telephone Number:
251-470-1671

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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