1467701490 NPI number — SOUTHERN ALABAMA PHYSICIANS LLP

Table of content: (NPI 1467701490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467701490 NPI number — SOUTHERN ALABAMA PHYSICIANS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ALABAMA PHYSICIANS LLP
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:
1467701490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CORPORATE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-609-1382
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4370 W MAIN ST
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:
36305-1056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-609-1382
Provider Business Practice Location Address Fax Number:
334-793-4613
Provider Enumeration Date:
09/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
DERIK
Authorized Official Middle Name:
K
Authorized Official Title or Position:
LLP MANAGING PARTNER
Authorized Official Telephone Number:
800-893-9698

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 007664700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142274 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007664700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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