Basic Information
| Provider Information | |||||||||
| NPI: | 1083678130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHC - PRINCETON OB/GYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 830605 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352830605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155943 | ||||||||
| FaxNumber: | 2057155932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | ENSLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352181619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057835164 | ||||||||
| FaxNumber: | 2057835167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | FENN | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2057155901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 529402530 | 05 | AL | MEDICAID |