1851336226 NPI number — RETINA SPECIALISTS OF ALABAMA IN MONTGOMERY LLC

Table of content: (NPI 1851336226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851336226 NPI number — RETINA SPECIALISTS OF ALABAMA IN MONTGOMERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA SPECIALISTS OF ALABAMA IN MONTGOMERY 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1851336226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 11TH AVENUE SOUTH
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-933-2625
Provider Business Mailing Address Fax Number:
205-558-2553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2055 NORMANDIE DR
Provider Second Line Business Practice Location Address:
SUITE 314
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36111-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-263-0105
Provider Business Practice Location Address Fax Number:
334-264-4386
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MASSEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
PAIGE
Authorized Official Title or Position:
MANAGING PHYSCIAN
Authorized Official Telephone Number:
334-263-0105

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1851336226 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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