1477014504 NPI number — DR. PERRIN FANT WINDHAM MD

Table of content: DR. PERRIN FANT WINDHAM MD (NPI 1477014504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477014504 NPI number — DR. PERRIN FANT WINDHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINDHAM
Provider First Name:
PERRIN
Provider Middle Name:
FANT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1477014504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-401-3057
Provider Business Mailing Address Fax Number:
318-868-6430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30500 HIGHWAY 181 36527
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SPANISH FORT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36527-3652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-410-5437
Provider Business Practice Location Address Fax Number:
251-434-3802
Provider Enumeration Date:
03/29/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD.44216 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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