Provider Demographics
NPI:1003977984
Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Other - Org Name:USA DEPARTMENT OF PEDIATRICS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:S
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-470-5842
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5842
Mailing Address - Fax:251-470-5809
Practice Address - Street 1:1504 SPRINGHILL AVENUE
Practice Address - Street 2:SUITE 1600
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-0130
Practice Address - Country:US
Practice Address - Phone:251-434-3915
Practice Address - Fax:251-434-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528300330Medicaid
MS09013347Medicaid
MS09013347Medicaid