Basic Information
| Provider Information | |||||||||
| NPI: | 1780043075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALABAMA PROVIDENCE HEALTHCARE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP-FOLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 AIRPORT BLVD | ||||||||
| Address2: | SUITE 143 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366086705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1851 N MCKENZIE ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365354700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2016 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516338880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102G702814 | 01 | AL | MEDICARE | OTHER | 156183 | 05 | AL | MEDICAID |