Basic Information
| Provider Information | |||||||||
| NPI: | 1720524689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOSA VALLEY - ARISTO ER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 830525 | ||||||||
| Address2: | DEPT SF69 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352830525 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2017 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | STREET | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | RICH | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2053135202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARISTO ER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.