Provider Demographics
NPI:1114356136
Name:GREATER AL HEALTH NETWORK
Entity Type:Organization
Organization Name:GREATER AL HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-345-5205
Mailing Address - Street 1:921 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7418
Mailing Address - Country:US
Mailing Address - Phone:205-345-1905
Mailing Address - Fax:
Practice Address - Street 1:921 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7418
Practice Address - Country:US
Practice Address - Phone:205-345-1905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL580500004Medicaid