1609898972 NPI number — KEITH J WINDHAM CRNA

Table of content: KEITH J WINDHAM CRNA (NPI 1609898972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609898972 NPI number — KEITH J WINDHAM CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINDHAM
Provider First Name:
KEITH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1609898972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULLMAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35056-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-737-2000
Provider Business Mailing Address Fax Number:
256-737-2849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1912 AL HIGHWAY 157
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPT
Provider Business Practice Location Address City Name:
CULLMAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35058-0609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-737-2882
Provider Business Practice Location Address Fax Number:
256-737-2849
Provider Enumeration Date:
07/24/2006

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: 367500000X , with the licence number:  1-065616 , 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: 51533380 . This is a "BCBS #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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