1720301054 NPI number — SOUTHERN HEMOPHILIA INFUSION

Table of content: (NPI 1720301054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720301054 NPI number — SOUTHERN HEMOPHILIA INFUSION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HEMOPHILIA INFUSION
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:
1720301054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 HAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY MINETTE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36507-4825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-937-8792
Provider Business Mailing Address Fax Number:
251-937-8793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 HAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY MINETTE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36507-4825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-937-8792
Provider Business Practice Location Address Fax Number:
251-937-8793
Provider Enumeration Date:
03/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-937-8792

Provider Taxonomy Codes

  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 113370 , 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: 0136413 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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