Provider Demographics
NPI:1093174286
Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Other - Org Name:PROVIDENCE MEDICAL GROUP - GULF SHORES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-8880
Mailing Address - Street 1:6701 AIRPORT BLVD
Mailing Address - Street 2:SUITE 143
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6705
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:1700 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-3422
Practice Address - Country:US
Practice Address - Phone:251-342-3949
Practice Address - Fax:251-631-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156183Medicaid
AL102G702814Medicare UPIN