Basic Information
| Provider Information | |||||||||
| NPI: | 1952814790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST MOBILE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3929-1 AIRPORT BLVD | ||||||||
| Address2: | 5TH FLOOR, ROOM 513 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513182681 | ||||||||
| FaxNumber: | 2513786222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 SCHILLINGER RD S | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366954136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516605950 | ||||||||
| FaxNumber: | 2516605949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2017 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MADISON | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING/ACT REP | ||||||||
| AuthorizedOfficialTelephone: | 2513182681 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 156183 | 05 | AL | MEDICAID |