Provider Demographics
NPI:1083643621
Name:PHYSICIAN PROFESSIONAL FEE COMPONENT
Entity Type:Organization
Organization Name:PHYSICIAN PROFESSIONAL FEE COMPONENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-533-8362
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35807
Mailing Address - Country:US
Mailing Address - Phone:256-533-7064
Mailing Address - Fax:256-704-0115
Practice Address - Street 1:101 SIVLEY RD
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-533-8362
Practice Address - Fax:256-533-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALCH7560OtherRAILROAD MEDICARE
ALF956OtherBLUE CROSS OF ALABAMA
ALCH7560OtherRAILROAD MEDICARE