Basic Information
| Provider Information | |||||||||
| NPI: | 1104095579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOBILE COUNTY BOARD OF HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MOBILE COUNTY HEALTH DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Practice Location | |||||||||
| Address1: | 5580 INN RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366191904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514108427 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2008 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLAUSMAN | ||||||||
| AuthorizedOfficialFirstName: | LINETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2516908837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0905X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
ID Information
| ID | Type | State | Issuer | Description | 590140056 | 05 | AL | MEDICAID |