1427252766 NPI number — MEDPEDS OF DOTHAN INC

Table of content: (NPI 1427252766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427252766 NPI number — MEDPEDS OF DOTHAN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDPEDS OF DOTHAN INC
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:
1427252766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
318 WESTGATE PARKWAY STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-671-2895
Provider Business Mailing Address Fax Number:
334-712-9430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 WESTGATE PKWY STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-2963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-671-2895
Provider Business Practice Location Address Fax Number:
334-712-9430
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOUTWELL
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATION
Authorized Official Telephone Number:
334-671-2895

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  00024928 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080A0000X , with the licence number: 00024928 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 009946055 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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