Provider Demographics
NPI:1386004372
Name:UNIVERSITY OF SOUTH ALABAMA
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA
Other - Org Name:USA STANTON ROAD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSO ADMIN OF AMBULATORY CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:IKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-470-1671
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:575 STANTON RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2344
Practice Address - Country:US
Practice Address - Phone:251-471-7207
Practice Address - Fax:251-471-7468
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF SOUTH ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty