1639146889 NPI number — DR. ALONZO J MAHURIN PHD., D.O.

Table of content: DR. ALONZO J MAHURIN PHD., D.O. (NPI 1639146889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639146889 NPI number — DR. ALONZO J MAHURIN PHD., D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHURIN
Provider First Name:
ALONZO
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD., D.O.
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:
1639146889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 NARROW LANE RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36116-2971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-613-3680
Provider Business Mailing Address Fax Number:
334-613-3685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4371 NARROW LANE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36116-2971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-613-3680
Provider Business Practice Location Address Fax Number:
334-613-3685
Provider Enumeration Date:
03/07/2006

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: 207Q00000X , with the licence number:  DO210 , 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: 630813275 . This is a "COMMERCIAL PRV" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 01 11606 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051008085 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080141135 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 630813275 . This is a "COMMERICIAL GRP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 630813275 . This is a "WORK COMP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000008085 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 630813275 . This is a "CHAMPUS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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