1508360181 NPI number — NEPHROLOGY VASCULAR LAB OF CENTRAL ALABAMA ASC LLC

Table of content: (NPI 1508360181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508360181 NPI number — NEPHROLOGY VASCULAR LAB OF CENTRAL ALABAMA ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEPHROLOGY VASCULAR LAB OF CENTRAL ALABAMA ASC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1508360181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 412142
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-2142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-8900
Provider Business Mailing Address Fax Number:
484-924-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1280 COLUMBIANA RD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VESTAVIA HILLS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35216-1642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-916-5201
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GLAZE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
610-644-8900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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