Basic Information
| Provider Information | |||||||||
| NPI: | 1144235870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF ALABAMA AT BIRMINGHAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UAB SELMA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1023 MEDICAL CENTER PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367016780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348754184 | ||||||||
| FaxNumber: | 3348743511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 MEDICAL CENTER PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367016780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348754184 | ||||||||
| FaxNumber: | 3348743511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DENNEY | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3348754184 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF ALABAMA AT BIRMINGHAM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529920870 | 05 | AL | MEDICAID | DB9926 | 01 | AL | RAILROAD MEDICARE | OTHER |