Basic Information
| Provider Information | |||||||||
| NPI: | 1023143484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BHC-BLOUNT & ETOWAH COUNTIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SNEAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13128 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352023128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155904 | ||||||||
| FaxNumber: | 2057155928 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 MEDICAL STREET | ||||||||
| Address2: | |||||||||
| City: | SNEAD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054667114 | ||||||||
| FaxNumber: | 2054663350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FENN | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF INTEGRATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2057155415 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 541003888 | 05 | AL | MEDICAID | 529301940 | 05 | AL | MEDICAID |