Basic Information
| Provider Information | |||||||||
| NPI: | 1407837750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF ALABAMA AT BIRMINGHAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UAB EMERGENCY DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DRAWER 624 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352460001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054376098 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Practice Location | |||||||||
| Address1: | 1806 SIXTH AVENUE SOUTH | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352490001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059757389 | ||||||||
| FaxNumber: | 2059754662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RACZYNSKI | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2059345121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF ALABAMA AT BIRMINGHAM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 374493800 | 01 | AL | DEPT OF LABOR (OWCP) | OTHER | 168372500 | 01 | AL | BLACK LUNG - DPT OF LABOR | OTHER | 529102510 | 05 | AL | MEDICAID | F786 | 01 | AL | BCBS PROVIDER NUMBER | OTHER | CC0720 | 01 | AL | RRMC PROVIDER NUMBER | OTHER |