Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 00007957 | AL |
Y | 208200000X | Surgeon | 7957 | AL |
Y | 208600000X | Surgeon | 7957 | AL |
NPI | 1023122421 |
---|---|
Provider Name | Mr. Edgar Tating Victoria |
First Address | Gadsden, AL 35902 |
Second Address | Gadsden, AL 35903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 25/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000046490 | (05) | AL |
009923940 | (05) | AL |
100906 | (05) | AL |
143752 (WADLEY) | (05) | AL |
143754 (ANNISTON) | (05) | AL |
143836 (CLEBURNE) | (05) | AL |
143995 (COMPLEX) | (05) | AL |
51046490 | BLUE CROSS (01) | AL |
51094372 | BLUECROSS (01) | AL |
630736845 | IRS TAXPER IDENTIFICATION (01) | AL |
C71080 | (02) | AL |