Basic Information
| Provider Information | |||||||||
| NPI: | 1083043178 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALABAMA PROVIDENCE HEALTHCARE SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850489 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366850489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 PROVIDENCE PARK DR E | ||||||||
| Address2: | BLDG 1, SUITE 102 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366954622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516395070 | ||||||||
| FaxNumber: | 2516342994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516331660 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALABAMA PROVIDENCE HEALTHCARE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.