Basic Information
| Provider Information | |||||||||
| NPI: | 1639293392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOUNTSVILLE HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13128 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352023128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155904 | ||||||||
| FaxNumber: | 2057155928 | ||||||||
| Practice Location | |||||||||
| Address1: | 68278 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350313370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054294151 | ||||||||
| FaxNumber: | 2057294604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | PANNELL | ||||||||
| AuthorizedOfficialFirstName: | NORMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALS | ||||||||
| AuthorizedOfficialTelephone: | 2567372882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CULLMAN REGIONAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529907730 | 05 | AL | MEDICAID |