1578512901 NPI number — PAUL JACKSON ANDERSON JR. MD

Table of content: PAUL JACKSON ANDERSON JR. MD (NPI 1578512901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578512901 NPI number — PAUL JACKSON ANDERSON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
PAUL
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1578512901
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:
PO BOX 1345
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POINT CLEAR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36564-1345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-928-9281
Provider Business Mailing Address Fax Number:
251-928-9281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 FILLINGIM ST
Provider Second Line Business Practice Location Address:
MASTIN BLDG. 617
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36617-2238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-470-5842
Provider Business Practice Location Address Fax Number:
251-470-5809
Provider Enumeration Date:
05/10/2006

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: 2085R0202X , with the licence number:  5393 , 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: 16-01418 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51530385 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 06029094 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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