Basic Information
| Provider Information | |||||||||
| NPI: | 1558325712 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHC - COMPREHENSIVE WOUND CARE CLINIC AT PRINCETON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 PRINCETON AVE SW | ||||||||
| Address2: | POB III; SUITE 210 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057833740 | ||||||||
| FaxNumber: | 2057833739 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 PRINCETON AVE SW | ||||||||
| Address2: | POB III; SUITE 210 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057833740 | ||||||||
| FaxNumber: | 2057833739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | VALETA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| 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 | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 529912980 | 05 | AL | MEDICAID |