1992588297 NPI number — MRS. ELIZABETH GRACE ANDERSON RD

Table of content: MRS. ELIZABETH GRACE ANDERSON RD (NPI 1992588297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992588297 NPI number — MRS. ELIZABETH GRACE ANDERSON RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
ELIZABETH
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAUL
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992588297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1723 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35401-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1723 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-773-8534
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2023

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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