1770666992 NPI number — RAYNARD FABIANKE, MEDICAL CLINIC OF RED BAY

Table of content: (NPI 1770666992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770666992 NPI number — RAYNARD FABIANKE, MEDICAL CLINIC OF RED BAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYNARD FABIANKE, MEDICAL CLINIC OF RED BAY
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:
1770666992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 429
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BAY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35582-0429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-356-9511
Provider Business Mailing Address Fax Number:
256-356-9339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 HOSPITAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED BAY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35582-3858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-356-9511
Provider Business Practice Location Address Fax Number:
256-356-9339
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COPELAND
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
256-532-1888

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CM2749 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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