Basic Information
| Provider Information | |||||||||
| NPI: | 1336257211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENTS EAST | ||||||||
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| OtherOrganizationName: | ST VINCENT'S EAST FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 MEDICAL PARK DR E | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352353401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058383343 | ||||||||
| FaxNumber: | 2058386119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2152 OLD SPRINGVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352154005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058386000 | ||||||||
| FaxNumber: | 2058386999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2058383718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. VINCENT'S EAST | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 528200780 | 05 | AL | MEDICAID | F736 | 01 | AL | MEDICARE PART B | OTHER |