Provider Demographics
NPI:1417037318
Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:AUTAUGA COUNTY HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STATE HOME CARE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GROVER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEDGEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-206-5341
Mailing Address - Street 1:201 MONROE ST
Mailing Address - Street 2:THE RSA TOWER, SUITE 1200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-3735
Mailing Address - Country:US
Mailing Address - Phone:334-206-5341
Mailing Address - Fax:334-206-5985
Practice Address - Street 1:219 N COURT ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3003
Practice Address - Country:US
Practice Address - Phone:334-361-3753
Practice Address - Fax:334-361-3806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-7801Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER