1184701369 NPI number — DR. CHARRELL MOYO BIRD MD

Table of content: DR. CHARRELL MOYO BIRD MD (NPI 1184701369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184701369 NPI number — DR. CHARRELL MOYO BIRD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRD
Provider First Name:
CHARRELL
Provider Middle Name:
MOYO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BULLARD
Provider Other First Name:
CHARRELL
Provider Other Middle Name:
MOYO
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184701369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-4200
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 W SHERMAN AVE
Provider Second Line Business Practice Location Address:
PEDIATRIX MEDICAL GROUP
Provider Business Practice Location Address City Name:
VINELAND
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08360-7059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-845-0100
Provider Business Practice Location Address Fax Number:
302-651-4945
Provider Enumeration Date:
11/01/2006

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: 2080N0001X , with the licence number:  MD424309 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 25MA09387400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1018646620001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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