1174519623 NPI number — STEPHEN L AVRAM MD

Table of content: STEPHEN L AVRAM MD (NPI 1174519623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174519623 NPI number — STEPHEN L AVRAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVRAM
Provider First Name:
STEPHEN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1174519623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2040 2ND AVE E
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ONEONTA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35121-2731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-274-9700
Provider Business Mailing Address Fax Number:
205-274-9714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 2ND AVE E
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ONEONTA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35121-2731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-274-9700
Provider Business Practice Location Address Fax Number:
205-274-9714
Provider Enumeration Date:
09/21/2005

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: 207R00000X , with the licence number:  013125 , 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: 051545771 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051554535 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521662 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009914076 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4046941 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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