1821113465 NPI number — ST. JUDE CATHOLIC HOSPITAL

Table of content: (NPI 1821113465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821113465 NPI number — ST. JUDE CATHOLIC HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JUDE CATHOLIC HOSPITAL
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:
1821113465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2048 W FAIRVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36108-4196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-834-5590
Provider Business Mailing Address Fax Number:
334-834-5602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 OAK STRRET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-834-5590
Provider Business Practice Location Address Fax Number:
334-834-5602
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PALOMARIA
Authorized Official First Name:
SAM
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
334-834-5590

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X , with the licence number:  N5104 , 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: 4754450S , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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