Basic Information
| Provider Information | |||||||||
| NPI: | 1497859052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF SOUTH ALABAMA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | USA HOSPITALS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40010 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2451 UNIVERSITY HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514717000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | OWEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CONTRACT OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2514717110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF SOUTH ALABAMA | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RX0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207ZP0102X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 09016178 | 05 | MS | MEDICAID | 529912620 | 05 | AL | MEDICAID | 09014887 | 05 | MS | MEDICAID | 09014877 | 05 | MS | MEDICAID | 09015184 | 05 | MS | MEDICAID |