Basic Information
| Provider Information | |||||||||
| NPI: | 1194789172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN DERMATOLOGY CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13128 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352023128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155904 | ||||||||
| FaxNumber: | 2057155928 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 PRINCETON AVE SW | ||||||||
| Address2: | POB II, SUITE 302 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057816995 | ||||||||
| FaxNumber: | 2057818783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | FENN | ||||||||
| AuthorizedOfficialFirstName: | G. | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF INTEGRATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2057155415 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 529904550 | 05 | AL | MEDICAID |