Basic Information
Provider Information | |||||||||
NPI: | 1801188503 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE HEALTHCARE SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE MEDICAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 850489 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366850489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2513423949 | ||||||||
FaxNumber: | 2516313361 | ||||||||
Practice Location | |||||||||
Address1: | 253 PROFESSIONAL LN | ||||||||
Address2: |   | ||||||||
City: | GULF SHORES | ||||||||
State: | AL | ||||||||
PostalCode: | 365423461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516313490 | ||||||||
FaxNumber: | 2516313461 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2011 | ||||||||
LastUpdateDate: | 08/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHRISTIANSON | ||||||||
AuthorizedOfficialFirstName: | CLARK | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2516313574 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 940365 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
ID | Type | State | Issuer | Description | 529907120 | 05 | AL |   | MEDICAID |