1326066010 NPI number — RANDY D. PROFFITT, M.D., LLC

Table of content: (NPI 1326066010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326066010 NPI number — RANDY D. PROFFITT, M.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDY D. PROFFITT, M.D., 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:
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:
1326066010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6317 PICCADILLY SQUARE DR
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:
36609-5103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-344-0322
Provider Business Mailing Address Fax Number:
251-344-0395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6317 PICCADILLY SQUARE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36609-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-344-0322
Provider Business Practice Location Address Fax Number:
251-344-0395
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PROFFITT
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-607-0300

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51531824 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051531824 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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