Basic Information
| Provider Information | |||||||||
| NPI: | 1144420936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGHILL DERMATOLOGY CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 OLD SHELL RD STE B | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366082036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513427880 | ||||||||
| FaxNumber: | 2513428369 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 OLD SHELL RD STE B | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366082036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513427880 | ||||||||
| FaxNumber: | 2513428369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BODIE | ||||||||
| AuthorizedOfficialFirstName: | BELEN | ||||||||
| AuthorizedOfficialMiddleName: | FRED | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2513427880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NI0002X | 6998 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology |
ID Information
| ID | Type | State | Issuer | Description | CG4447 | 01 | AL | MEDICARE RAILROAD | OTHER | 51004869 | 01 | AL | BLUE CROSS AND BLUE SHIELD | OTHER |