|Provider Name||DR. BRUNDA REVANNA M.D.|
|Provider Location Address||1465A 1ST AVE SW STE A JACKSONVILLE, AL 36265|
|Provider Mailing Address||950 EAGLES LANDING PWKY #321 STOCKBRIDGE, GA 30281|
|NPI Entity Type||Individual|
|Medical School Name||MERCER UNIVERSITY SCHOOL OF MEDICINE|
|Is Sole Proprietor?||Yes|
|Is Organization Subpart?||N/A|
|Last Update Date||06-15-2015|
DR. BRUNDA REVANNA M.D.
1465A 1ST AVE SW STE A
Phone: (256) 435-8383
DR. BRUNDA REVANNA M.D.
950 EAGLES LANDING PWKY #321
Phone: (678) 432-4755
Fax: (678) 432-4753
Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.
|Identifier||Type / Code||Identifier State|
|051517109||MEDICARE ID-TYPE UNSPECIFIED (04)||AL|
|H3509||MEDICARE UPIN (02)||AL|
What is the National Provider Indentifier (NPI)?
The NPI is 10-position all-numeric identification number assigned by the NPPES to uniquely identify a health care provider.
Provider Location Address
The location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Mailing Address
The mailing address of the provider being identified. This address may contain the same information as the provider location address.
Entity Type Code
The code describing the type of health care provider that is being assigned an NPI.
The entity type codes are:
1 = Person: individual human being who furnishes health care;
2 = Non-person: entity other than an individual human being that furnishes health care (Examples: hospital, SNF, hospital subunit, pharmacy, or HMO)
What is a Subpart?
Subparts are the components and separate physical locations of organization health care providers. Subpart examples include:
Hospital components include outpatient departments, surgical centers, psychiatric units, and laboratories. These components are often separately licensed or certified by States and may exist at physical locations other than that of the hospital of which they are a component.
Provider Other Organization Name
The other organization name is the alternative last name by which the provider is or has been known (if an individual) or other name by which the organization provider is or has been known. The code identifying the type of other name. The provider other organization name codes are:
1 = former name;
2 = professional name;
3 = doing business as (d/b/ a) name;
4 = former legal business name; :
5 = other.
Provider Enumeration Date
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date
The date that a NPI record was last updated or changed.
Primary Taxonomy Code
The primary taxonomy code defines the provider type, classification, and specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.
Authorized Official Name
The name of the person authorized to submit the NPI application or to officially change data for a health care provider.