Provider Demographics
NPI:1093048332
Name:BLAN, JIMMIE COUNCIL (PA)
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:COUNCIL
Last Name:BLAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEMORIAL HOSPITAL DR
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1183
Mailing Address - Country:US
Mailing Address - Phone:251-342-2641
Mailing Address - Fax:251-343-9507
Practice Address - Street 1:100 MEMORIAL HOSPITAL DR
Practice Address - Street 2:SUITE 3A
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1183
Practice Address - Country:US
Practice Address - Phone:251-342-2641
Practice Address - Fax:251-343-9507
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA1692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1093048332Medicaid
AL05110015OtherBLUE CROSS/BLUE SHIELD
AL1093048332Medicare PIN