Basic Information
| Provider Information | |||||||||
| NPI: | 1386053783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GMUC OF TILLMANS CORNER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 RANGELINE SERVICE RD N | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366199504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | 2514453722 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 RANGELINE SERVICE RD N | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366199504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | 2514453722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2014 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | WATERS | ||||||||
| AuthorizedOfficialFirstName: | DARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2516330123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.