Basic Information
| Provider Information | |||||||||
| NPI: | 1780251058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EAST ALABAMA HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENIOR BEHAVIORAL HEALTH AT EAMC-LANIER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 348 | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347569180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4800 48TH ST | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368543666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347569180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3345281310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE EAST ALABAMA HEALTH CARE AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.