Basic Information
| Provider Information | |||||||||
| NPI: | 1023358850 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UAB CALLAHAN EYE HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANESTHESIA AT CALLAHAN EYE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660685 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352660685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053258100 | ||||||||
| FaxNumber: | 2053258809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 11/16/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SADLER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2053258100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UAB CALLAHAN EYE HOSPITAL AUTHORITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 145975 | 05 | AL | MEDICAID |