Provider Demographics
NPI:1427407428
Name:BODYLOGICMD OF BIRMINGHAM
Entity Type:Organization
Organization Name:BODYLOGICMD OF BIRMINGHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONOHUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-402-9602
Mailing Address - Street 1:403 JUNIPER MILL TRCE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9601
Mailing Address - Country:US
Mailing Address - Phone:770-402-9602
Mailing Address - Fax:
Practice Address - Street 1:1024 EDENTON ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-9258
Practice Address - Country:US
Practice Address - Phone:866-460-3246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD17416261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care