1538176839 NPI number — DAVID P BLEDSOE OTR

Table of content: DAVID P BLEDSOE OTR (NPI 1538176839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538176839 NPI number — DAVID P BLEDSOE OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLEDSOE
Provider First Name:
DAVID
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
M

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:
1538176839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7088 UNIVERSITY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36117-6992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-396-1400
Provider Business Mailing Address Fax Number:
334-396-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2090 COLUMBIANA RD
Provider Second Line Business Practice Location Address:
1900
Provider Business Practice Location Address City Name:
VESTAVIA HILLS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35216-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-978-2358
Provider Business Practice Location Address Fax Number:
205-978-2367
Provider Enumeration Date:
08/01/2006

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: 225X00000X , with the licence number:  0514 , 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)

  • Identifier: 051534637 . This is a "BC/BS PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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