1609095157 NPI number — HEART GROUP OF THE EASTERN SHORE, P.C.

Table of content: (NPI 1609095157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609095157 NPI number — HEART GROUP OF THE EASTERN SHORE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEART GROUP OF THE EASTERN SHORE, P.C.
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:
6
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:
1609095157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-0266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-990-1920
Provider Business Mailing Address Fax Number:
251-990-1921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S. INGLESIDE STREET
Provider Second Line Business Practice Location Address:
#4 MEDICAL PARK
Provider Business Practice Location Address City Name:
FAIRHOPE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36532-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-990-1920
Provider Business Practice Location Address Fax Number:
251-990-1921
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PURSLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
251-990-1920

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25610 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009936436 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009936467 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609095157 . This is a "GRP NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51503479 . This is a "BC/MC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: DE4413 . This is a "RR MEDICARE FOR GROUP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009936433 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051554382 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05538519 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1467430777 . This is a "NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1689678674 . This is a "BRAND NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: K814 . This is a "MEDICARE GRP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529927690 . This is a "GRP MEDICAID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51541652 . This is a "MEDICARE BRAND" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00082012 . This is a "RR MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009936434 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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