1902974561 NPI number — SOUTHEASTERN PAIN MANAGEMENT LLC

Table of content: (NPI 1902974561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902974561 NPI number — SOUTHEASTERN PAIN MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN PAIN MANAGEMENT LLC
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:
1902974561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1026 GOODYEAR AVE
Provider Second Line Business Mailing Address:
BLDG 400 STE 302
Provider Business Mailing Address City Name:
GADSDEN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35903-1102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-492-7246
Provider Business Mailing Address Fax Number:
256-492-1168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1026 GOODYEAR AVE
Provider Second Line Business Practice Location Address:
BLDG 400 STE 302
Provider Business Practice Location Address City Name:
GADSDEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35903-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-492-7246
Provider Business Practice Location Address Fax Number:
256-492-1168
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS-MURATTA
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
256-492-7246

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51521436 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00145166 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: D97686 . This is a "HEALTHSPRINGS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: D97686 . This is a "HUMANA GOLD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com