1639337934 NPI number — ENT BESSEMER, LLC

Table of content: (NPI 1639337934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639337934 NPI number — ENT BESSEMER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENT BESSEMER, LLC
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:
1639337934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
985 9TH AVE SW
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
BESSEMER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35022-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-481-7780
Provider Business Mailing Address Fax Number:
205-481-7740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
985 9TH AVE SW
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
BESSEMER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35022-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-481-7780
Provider Business Practice Location Address Fax Number:
205-481-7740
Provider Enumeration Date:
05/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GILLILAND
Authorized Official First Name:
GRETCHEN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
BILLING
Authorized Official Telephone Number:
205-481-7780

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  12109 , 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: 1010135 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 51045124 . This is a "BLUE CROSS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 420842449 . This is a "TRICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 529900180 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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