Basic Information
| Provider Information | |||||||||
| NPI: | 1952617508 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GMUC OF SPRINGHILL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GMUC OF SPRINGHILL LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7943 MOFFETT RD | ||||||||
| Address2: | |||||||||
| City: | SEMMES | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365755409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | 2514453722 | ||||||||
| Practice Location | |||||||||
| Address1: | 4402 OLD SHELL RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | 2514453722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | WATERS | ||||||||
| AuthorizedOfficialFirstName: | DARREN | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2516330123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.