1891976833 NPI number — KEN K DAVENPORT M.D.

Table of content: KEN K DAVENPORT M.D. (NPI 1891976833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891976833 NPI number — KEN K DAVENPORT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVENPORT
Provider First Name:
KEN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1891976833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 GOODYEAR AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
GADSDEN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35903-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-492-0020
Provider Business Mailing Address Fax Number:
256-492-0029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 GOODYEAR AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GADSDEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35903-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-492-0020
Provider Business Practice Location Address Fax Number:
256-492-0029
Provider Enumeration Date:
11/19/2007

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: 208600000X , with the licence number:  29230 , 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: 130499 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511-17039 . This is a "BLUE CROSS BLUE SHIELD ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: D570 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529203130 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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