Provider Demographics
NPI:1104859123
Name:EASTERN HOSPITAL MEDICINE PC
Entity Type:Organization
Organization Name:EASTERN HOSPITAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WIMBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-874-8300
Mailing Address - Street 1:PO BOX 830674
Mailing Address - Street 2:MSC#716
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0674
Mailing Address - Country:US
Mailing Address - Phone:205-874-8300
Mailing Address - Fax:205-874-8333
Practice Address - Street 1:50 MEDICAL PARK EAST DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235
Practice Address - Country:US
Practice Address - Phone:205-838-3000
Practice Address - Fax:205-874-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF1683OtherMEDICARE RAILROAD
AL529930180Medicaid
DF1683OtherMEDICARE RAILROAD