1548310741 NPI number — TENNESSEE RIVER EYE CLINIC

Table of content: (NPI 1548310741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548310741 NPI number — TENNESSEE RIVER EYE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE RIVER EYE CLINIC
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:
1548310741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 S. MONTGOMERY AVE
Provider Second Line Business Mailing Address:
HELEN KELLER HOSPITAL CAMPUS
Provider Business Mailing Address City Name:
SHEFFIELD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35660-6350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-381-2020
Provider Business Mailing Address Fax Number:
256-381-7754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 S. MONTGOMERY AVE
Provider Second Line Business Practice Location Address:
HELEN KELLER HOSPITAL CAMPUS
Provider Business Practice Location Address City Name:
SHEFFIELD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35660-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-381-2020
Provider Business Practice Location Address Fax Number:
256-381-7754
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KASSELS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
256-381-2020

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  16162 , 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: 0810284 . This is a "SPA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 168150600 . This is a "COMMERCIAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529901280 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180036556 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5567071 . This is a "COMMERCIAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000008486A . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000008486 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261210236 . This is a "COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3125128 . This is a "COMMERCIAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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