Basic Information
| Provider Information | |||||||||
| NPI: | 1154832921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMC OF ALABAMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 CENTENNIAL BLVD. | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323080536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506561837 | ||||||||
| FaxNumber: | 8508772917 | ||||||||
| Practice Location | |||||||||
| Address1: | 5101 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506561837 | ||||||||
| FaxNumber: | 8508772917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2017 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8506561837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COSPT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT, DIP MDT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.