1417663576 NPI number — ANDALUSIA PHYSICIAN PRACTICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417663576 NPI number — ANDALUSIA PHYSICIAN PRACTICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDALUSIA PHYSICIAN PRACTICES 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:
1417663576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 S 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-546-3733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
847 W BYPASS STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDALUSIA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36420-4747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-428-2273
Provider Business Practice Location Address Fax Number:
334-222-1150
Provider Enumeration Date:
01/23/2023

Additional Information

Authorized Official

Authorized Official Last Name:
TEAGUE
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT, CORPORATE SECRETARY
Authorized Official Telephone Number:
629-253-5121

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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