Provider Demographics
NPI:1417093766
Name:UNIVERSITY DIAGNOSTICS,LLC
Entity Type:Organization
Organization Name:UNIVERSITY DIAGNOSTICS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEWSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-553-9171
Mailing Address - Street 1:701 UNIVERSITY BLVD E STE 204
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7431
Mailing Address - Country:US
Mailing Address - Phone:205-553-9171
Mailing Address - Fax:205-553-9127
Practice Address - Street 1:701 UNIVERSITY BLVD E STE 204
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7431
Practice Address - Country:US
Practice Address - Phone:205-553-9171
Practice Address - Fax:205-553-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21330323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
051558457OtherBLUE CROSS BLUE SHIELD
051558457OtherBLUE CROSS BLUE SHIELD