Provider Demographics
NPI:1275828659
Name:IMC OTOLARYNGOLOGY FACIAL PLASTIC & RECONSTRUCTIVE SURGERY, P.C.
Entity Type:Organization
Organization Name:IMC OTOLARYNGOLOGY FACIAL PLASTIC & RECONSTRUCTIVE SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-463-2010
Mailing Address - Street 1:3401 MEDICAL PARK DR
Mailing Address - Street 2:BLDG 1, SUITE 103
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3318
Mailing Address - Country:US
Mailing Address - Phone:251-463-2010
Mailing Address - Fax:
Practice Address - Street 1:3401 MEDICAL PARK DR
Practice Address - Street 2:BLDG 1, SUITE 103
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-3318
Practice Address - Country:US
Practice Address - Phone:251-463-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty