Provider Demographics
NPI:1093316259
Name:UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY
Other - Org Name:MOBILE DIAGNOSTIC CENTER - MIDTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-318-2681
Mailing Address - Street 1:3929-1 AIRPORT BLVD
Mailing Address - Street 2:5TH FLOOR, ROOM 513
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609
Mailing Address - Country:US
Mailing Address - Phone:251-318-2681
Mailing Address - Fax:251-378-6222
Practice Address - Street 1:2505 OLD SHELL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3021
Practice Address - Country:US
Practice Address - Phone:251-660-6400
Practice Address - Fax:251-660-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty