Basic Information
Provider Information | |||||||||
NPI: | 1639330632 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DREXIS, LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 21 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319020021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8665933318 | ||||||||
FaxNumber: | 2053135245 | ||||||||
Practice Location | |||||||||
Address1: | 4401 RIVER CHASE DR | ||||||||
Address2: |   | ||||||||
City: | PHENIX CITY | ||||||||
State: | AL | ||||||||
PostalCode: | 368677483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8665933318 | ||||||||
FaxNumber: | 2053135245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2008 | ||||||||
LastUpdateDate: | 08/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENDRIX | ||||||||
AuthorizedOfficialFirstName: | RONNIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3347323249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.