Basic Information
| Provider Information | |||||||||
| NPI: | 1164683595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTHCARE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850489 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366850489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Practice Location | |||||||||
| Address1: | 29653 ANCHOR CROSS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAPHNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365269594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516313490 | ||||||||
| FaxNumber: | 2516313461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIANSON | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516313574 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 529907120 | 05 | AL | MEDICAID |