Basic Information
| Provider Information | |||||||||
| NPI: | 1245361120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHC-DEKALB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MEDICAL CENTER DR SW | ||||||||
| Address2: | |||||||||
| City: | FORT PAYNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359683421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569972820 | ||||||||
| FaxNumber: | 2569972890 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BEACON PKWY W | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352093102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155910 | ||||||||
| FaxNumber: | 2057155928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | FAULKNER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2057155901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH CENTERS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.