Provider Demographics
NPI:1093852329
Name:BULLEN, MAX BLANE
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:BLANE
Last Name:BULLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 CANTER WAY
Mailing Address - Street 2:
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-7610
Mailing Address - Country:US
Mailing Address - Phone:205-621-5240
Mailing Address - Fax:
Practice Address - Street 1:BAPITIST MEDICAL CENTER SOUTH,2105 EAST SOUTH BOULEVARD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:38111-0010
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-054439367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00168Medicare UPIN