Basic Information
| Provider Information | |||||||||
| NPI: | 1588721773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALABAMA COLON & RECTAL INSTITUTE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1317 4TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054585000 | ||||||||
| FaxNumber: | 2054585005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1317 4TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054585000 | ||||||||
| FaxNumber: | 2054585005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | COYLE | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054585000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | CE0105 | 01 | AL | RAILROAD MEDICARE | OTHER |