1760409874 NPI number — ADA MYRIAM PERALTA-CARCELEN M.D.

Table of content: ADA MYRIAM PERALTA-CARCELEN M.D. (NPI 1760409874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760409874 NPI number — ADA MYRIAM PERALTA-CARCELEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERALTA-CARCELEN
Provider First Name:
ADA
Provider Middle Name:
MYRIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PERALTA
Provider Other First Name:
MYRIAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1760409874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 VOLKER HALL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35294-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-934-3795
Provider Business Mailing Address Fax Number:
205-975-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 6TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35233-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-939-9096
Provider Business Practice Location Address Fax Number:
205-975-6503
Provider Enumeration Date:
07/16/2006

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: 208000000X , with the licence number:  15068 , 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: 000083222 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1210029 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000028826 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009999655 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510-83222 . This is a "BC BS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: E40209 . This is a "VIVA" identifier . This identifiers is of the category "OTHER".




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