Basic Information
| Provider Information | |||||||||
| NPI: | 1740458967 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVI PHYSICIAN SERVICES I, LLC | ||||||||
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| OtherOrganizationName: | ST VINCENT'S BLOUNT HOSPITALIST DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352051601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059894833 | ||||||||
| FaxNumber: | 2058383102 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 GILBREATH DR | ||||||||
| Address2: | |||||||||
| City: | ONEONTA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351212827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052743010 | ||||||||
| FaxNumber: | 2052743002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | CORNEJO | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2058383718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.