Basic Information
| Provider Information | |||||||||
| NPI: | 1043205032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PHYSICIANS GROUP ATHENS-LIMESTONE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DRAWER 314 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352460001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054376098 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356112457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562659891 | ||||||||
| FaxNumber: | 2565188276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | NATHANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2562659891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | F791 | 01 | AL | BCBS | OTHER | C16253 | 01 | AL | RR MEDICARE | OTHER |