Basic Information
| Provider Information | |||||||||
| NPI: | 1245294339 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BHC - GARDENDALE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BBH PCN GARDENDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 758 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056315521 | ||||||||
| FaxNumber: | 2056315540 | ||||||||
| Practice Location | |||||||||
| Address1: | 758 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056315521 | ||||||||
| FaxNumber: | 2056315540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | VALETA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2057155901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529402550 | 05 | AL | MEDICAID |