1336229988 NPI number — STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH

Table of content: (NPI 1336229988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336229988 NPI number — STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
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:
1336229988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 MONROE ST
Provider Second Line Business Mailing Address:
THE RSA TOWER, SUITE1200
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36104-3830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-206-5341
Provider Business Mailing Address Fax Number:
334-206-5985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20371 CLYDE MABRY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35611-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-230-0434
Provider Business Practice Location Address Fax Number:
256-230-9289
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEDGEWORTH
Authorized Official First Name:
GROVER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
STATE HOME CARE DIRECTOR
Authorized Official Telephone Number:
334-206-5341

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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