Basic Information
Provider Information | |||||||||
NPI: | 1477891331 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDSOUTH MERIDIANVILLE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12287 HIGHWAY 231 431 N | ||||||||
Address2: |   | ||||||||
City: | MERIDIANVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 357591205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568281154 | ||||||||
FaxNumber: | 2568281194 | ||||||||
Practice Location | |||||||||
Address1: | 12287 HIGHWAY 231 431 N | ||||||||
Address2: |   | ||||||||
City: | MERIDIANVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 357591205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568281154 | ||||||||
FaxNumber: | 2568281194 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2013 | ||||||||
LastUpdateDate: | 04/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAUGH | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2052536739 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.