1497959613 NPI number — PROVIDENCE HEALTHCARE SERVICES

Table of content: MRS. SUSAN CHERYL DROWN COTAL (NPI 1528288271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497959613 NPI number — PROVIDENCE HEALTHCARE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTHCARE SERVICES
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:
PROVIDENCE MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1497959613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-342-3949
Provider Business Mailing Address Fax Number:
251-631-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5621 COTTAGE HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36609-4210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-666-2439
Provider Business Practice Location Address Fax Number:
251-666-3166
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-631-3574

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 529907120 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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