1699746552 NPI number — DR. JERRY BRENT WILLIAMS M.D.

Table of content: DR. JERRY BRENT WILLIAMS M.D. (NPI 1699746552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699746552 NPI number — DR. JERRY BRENT WILLIAMS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
JERRY
Provider Middle Name:
BRENT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1699746552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 FRANKLIN ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35801-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-539-4080
Provider Business Mailing Address Fax Number:
256-539-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 S JACKSON HWY
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SHEFFIELD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35660-5777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-381-8811
Provider Business Practice Location Address Fax Number:
256-381-5151
Provider Enumeration Date:
01/30/2006

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: 207RC0000X , with the licence number:  11854 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0200X , with the licence number: 11854 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 25-10012 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07887859 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112590 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112603 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4198103 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 510-49320 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 510-49461 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51049461 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51521840 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00138871 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00742166 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009954995 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112594 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510-49319 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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