Provider Demographics
NPI:1407042740
Name:EAST ALABAMA NEUROLOGY INC
Entity Type:Organization
Organization Name:EAST ALABAMA NEUROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:CHIVUKULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-887-0955
Mailing Address - Street 1:3120 FREDERICK RD STE I
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-7135
Mailing Address - Country:US
Mailing Address - Phone:334-887-0955
Mailing Address - Fax:334-887-0964
Practice Address - Street 1:3120 FREDERICK RD
Practice Address - Street 2:SUITE I
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-7134
Practice Address - Country:US
Practice Address - Phone:334-887-0955
Practice Address - Fax:334-887-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3874174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL52906460Medicaid
AL52906460Medicaid