Provider Demographics
NPI:1114021409
Name:OBSTETRICS & GYNECOLOGY OF DOTHAN INC
Entity type:Organization
Organization Name:OBSTETRICS & GYNECOLOGY OF DOTHAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-671-9445
Mailing Address - Street 1:104 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-671-9445
Mailing Address - Fax:334-836-0059
Practice Address - Street 1:104 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-671-9445
Practice Address - Fax:334-836-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23245207V00000X
ALDO1161207V00000X
AL31759207V00000X
AL31756207V00000X
AL32437207V00000X
ALPA-204363A00000X
AL1006758363LX0001X
AL207V00000X
AL26014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01D2068157OtherCLIA WAVIER
01D0989955OtherCLIA WAIVED
1826OtherMEDICARE GROUP NUMBER
C47766OtherMEDICAL PROTECTIVE
529928670OtherMEDICAID GROUP
AL01D2043043OtherCLIA WAIVED
AL051502953Medicaid
AL01D2052896OtherCLIA WAIVED
01D2074304OtherCLIA WAIVED
AL051520983Medicaid
AL01D2043043OtherCLIA WAIVED
529928670OtherMEDICAID GROUP
C47766OtherMEDICAL PROTECTIVE
AL051520983Medicare PIN