Provider Demographics
NPI:1235541418
Name:GARDENDALE SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:GARDENDALE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-396-6930
Mailing Address - Street 1:PO BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:334-386-2051
Mailing Address - Fax:334-481-1200
Practice Address - Street 1:2213 DECATUR HWY
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2301
Practice Address - Country:US
Practice Address - Phone:205-418-6021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty