Provider Demographics
NPI:1043321300
Name:EDWARDS LAKE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:EDWARDS LAKE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:JACKI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-699-1632
Mailing Address - Street 1:3240 EDWARDS LAKE PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3117
Mailing Address - Country:US
Mailing Address - Phone:205-949-1414
Mailing Address - Fax:205-949-1415
Practice Address - Street 1:3240 EDWARDS LAKE PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3117
Practice Address - Country:US
Practice Address - Phone:205-949-1414
Practice Address - Fax:205-949-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00013482174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1316985062OtherINDIVIDUAL NPI
AL1316985062OtherINDIVIDUAL NPI