Basic Information
Provider Information | |||||||||
NPI: | 1770534901 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONTGOMERY BAPTIST OUTREACH SERVICES CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONTGOMERY FAMILY MEDICINE RESIDENCY PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4371 NARROW LANE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361162971 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346133680 | ||||||||
FaxNumber: | 3346133685 | ||||||||
Practice Location | |||||||||
Address1: | 4371 NARROW LANE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361162971 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346133680 | ||||||||
FaxNumber: | 3346133685 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 04/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUTON | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3342734258 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/09/2020 |
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 | 0113048 | 01 | AL | UNITED HEALTHCARE | OTHER | CC9180 | 01 | AL | RAILROAD MEDICARE | OTHER | 529904250 | 05 | AL |   | MEDICAID |