Basic Information
| Provider Information | |||||||||
| NPI: | 1053571588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCARE AUTHORITY OF ELBA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELBA PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 987 DRAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELBA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363231402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348972257 | ||||||||
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| Practice Location | |||||||||
| Address1: | 987 DRAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELBA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363231402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348972257 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRILEY | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3348972257 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHCARE AUTHORITY OF ELBA INC | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 558300170 | 05 | AL | MEDICAID |