Basic Information
Provider Information | |||||||||
NPI: | 1861875361 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST ALABAMA REGIONAL HEALTHCARE AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EUFAULA FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 820 W WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | EUFAULA | ||||||||
State: | AL | ||||||||
PostalCode: | 360271822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346887127 | ||||||||
FaxNumber: | 3346887127 | ||||||||
Practice Location | |||||||||
Address1: | 617B E BROAD ST | ||||||||
Address2: |   | ||||||||
City: | EUFAULA | ||||||||
State: | AL | ||||||||
PostalCode: | 360271710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346887128 | ||||||||
FaxNumber: | 3346887127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2015 | ||||||||
LastUpdateDate: | 07/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALTERS | ||||||||
AuthorizedOfficialFirstName: | LYNDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3346887128 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-10198 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1-100198 | 01 | AL | TEMPORARY LICENSES # | OTHER |