Basic Information
| Provider Information | |||||||||
| NPI: | 1962862078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF SOUTH ALABAMA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | USA GASTROENTEROLOGY- ADULT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343626 | ||||||||
| FaxNumber: | 2514452464 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 S UNIVERSITY BLVD UCOM 6000 B | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366880002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516605555 | ||||||||
| FaxNumber: | 2516605559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | IKNER | ||||||||
| AuthorizedOfficialFirstName: | HARVEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSO ADMIN OF AMBULATORY CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 2514701671 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF SOUTH ALABAMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.