1962890178 NPI number — DOTHAN INTERNAL MEDICINE, LLC

Table of content: (NPI 1962890178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962890178 NPI number — DOTHAN INTERNAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOTHAN INTERNAL MEDICINE, 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:
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:
1962890178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 ROSS CLARK CIR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-699-2004
Provider Business Mailing Address Fax Number:
334-699-2006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 ROSS CLARK CIR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-699-2004
Provider Business Practice Location Address Fax Number:
334-699-2006
Provider Enumeration Date:
12/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BEUACHAMP
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
334-699-2004

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  20759 , 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: 1003831983 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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