Basic Information
| Provider Information | |||||||||
| NPI: | 1013115294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHC-MEDSTAT OF JASPER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 BEACON PKWY W | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352093102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155910 | ||||||||
| FaxNumber: | 2057155928 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 HIGHWAY 78 E | ||||||||
| Address2: | MEDICAL ARTS TOWER; SUITE 109 | ||||||||
| City: | JASPER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355018907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053871891 | ||||||||
| FaxNumber: | 2053878227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | RAMSEY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | PRINGLE | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2057155901 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | L274 | 01 | AL | MEDICARE GROUP | OTHER |