Basic Information
Provider Information | |||||||||
NPI: | 1043593759 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST HEALTH CENTERS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BBH PRIMARY AND SPECIALTY CARE NETWORK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1130 22ND ST S STE 1000 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352052881 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2057155943 | ||||||||
FaxNumber: | 2057155932 | ||||||||
Practice Location | |||||||||
Address1: | 1130 22ND ST S STE 1000 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352052881 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2057155943 | ||||||||
FaxNumber: | 2057155932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2011 | ||||||||
LastUpdateDate: | 01/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2057155943 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
ID | Type | State | Issuer | Description | 134317 | 05 | AL |   | MEDICAID |