1265426720 NPI number — DR. LEISA W DEVENNY MD

Table of content: DR. LEISA W DEVENNY MD (NPI 1265426720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265426720 NPI number — DR. LEISA W DEVENNY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVENNY
Provider First Name:
LEISA
Provider Middle Name:
W
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:
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:
1265426720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 934370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-897-6169
Provider Business Mailing Address Fax Number:
800-897-6170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 UNIVERSITY BLVD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-759-7111
Provider Business Practice Location Address Fax Number:
205-343-8549
Provider Enumeration Date:
09/09/2005

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: 207L00000X , with the licence number:  18211 , 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: 000078713 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com