Provider Demographics
NPI:1831360601
Name:DECATUR MAXILLOFACIAL & COSMETIC SURGERY CENTER
Entity type:Organization
Organization Name:DECATUR MAXILLOFACIAL & COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:LITTLEJOHN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:256-355-8224
Mailing Address - Street 1:2023 DANVILLE PARK DR SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1833
Mailing Address - Country:US
Mailing Address - Phone:256-355-8224
Mailing Address - Fax:256-355-8819
Practice Address - Street 1:2023 DANVILLE PARK DR SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1833
Practice Address - Country:US
Practice Address - Phone:256-355-8224
Practice Address - Fax:256-355-8819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000026618OtherMEDICARE PROVIDER NUMBER
AL529700210Medicaid
AL529700210Medicaid