Basic Information
Provider Information | |||||||||
NPI: | 1497746085 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIABETES CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIABETES CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1792 AL HIGHWAY 157 | ||||||||
Address2: |   | ||||||||
City: | CULLMAN | ||||||||
State: | AL | ||||||||
PostalCode: | 350583622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2567372025 | ||||||||
FaxNumber: | 2567372829 | ||||||||
Practice Location | |||||||||
Address1: | 1792 AL HIGHWAY 157 | ||||||||
Address2: |   | ||||||||
City: | CULLMAN | ||||||||
State: | AL | ||||||||
PostalCode: | 350583622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2567372025 | ||||||||
FaxNumber: | 2567372829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDMISSON | ||||||||
AuthorizedOfficialFirstName: | JETE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2567372595 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | H0S0035H | 05 | AL |   | MEDICAID | 010049 | 01 | AL | BLUE CROSS | OTHER |