1316101769 NPI number — WEST ALABAMA PHYSICIAN ASSOCIATES, LLC

Table of content: (NPI 1316101769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316101769 NPI number — WEST ALABAMA PHYSICIAN ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST ALABAMA PHYSICIAN ASSOCIATES, LLC
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:
1316101769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 UNIVERSITY BLVD E
Provider Second Line Business Mailing Address:
SUITE 908
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35401-7423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-344-9393
Provider Business Mailing Address Fax Number:
205-758-6750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 UNIVERSITY BLVD E
Provider Second Line Business Practice Location Address:
SUITE 908
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-7423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-344-9393
Provider Business Practice Location Address Fax Number:
205-758-6750
Provider Enumeration Date:
07/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CONVILLE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
CLAY
Authorized Official Title or Position:
CORP DIRECTOR, PHYSICIAN SERVICES
Authorized Official Telephone Number:
205-759-6165

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103891 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: D03406 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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