1558410167 NPI number — NORTHPORT INTERNAL MEDICINE PC

Table of content: (NPI 1558410167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558410167 NPI number — NORTHPORT INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHPORT INTERNAL MEDICINE PC
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:
1558410167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
952 ROSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHPORT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35476-3363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-339-8282
Provider Business Mailing Address Fax Number:
208-339-0936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
952 ROSE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHPORT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35476-3363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-339-8282
Provider Business Practice Location Address Fax Number:
208-339-0936
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWNE
Authorized Official First Name:
PAM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
205-339-8282

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  12788 , 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: 0410625 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: H018 . This is a "MEDICARE IDENTIFIER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 528801430 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010021562 . This is a "MEDICARE TRAVELERS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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