Provider Demographics
NPI:1598827420
Name:EAST ALABAMA CARDIAC AND THORACIC SURGERY
Entity Type:Organization
Organization Name:EAST ALABAMA CARDIAC AND THORACIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-528-1720
Mailing Address - Street 1:2000 PEPPERELL PKWY
Mailing Address - Street 2:PO BOX 2740
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5452
Mailing Address - Country:US
Mailing Address - Phone:334-528-1720
Mailing Address - Fax:334-528-1693
Practice Address - Street 1:2000 PEPPERELL PKWY
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5452
Practice Address - Country:US
Practice Address - Phone:334-528-1720
Practice Address - Fax:334-528-1693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19855174400000X
AL22312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009960240Medicaid
AL110274Medicaid
AL051502404Medicare ID - Type UnspecifiedLEE D. ROBERSON, MD
AL009960240Medicaid
AL102I783675Medicare PIN
AL110274Medicaid