Provider Demographics
NPI:1437258373
Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity Type:Organization
Organization Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Other - Org Name:COMMUNITY HLTH SVCS-FAMILY PHY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF AMBULATORY OPERATI
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:205-934-7862
Mailing Address - Street 1:1201 11TH AVE S
Mailing Address - Street 2:3RD FLOOR PHARMACY
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-3410
Mailing Address - Country:US
Mailing Address - Phone:205-930-7585
Mailing Address - Fax:205-930-7587
Practice Address - Street 1:930 20TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2610
Practice Address - Country:US
Practice Address - Phone:205-975-7792
Practice Address - Fax:205-975-6962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1111753336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1993075OtherPK
AL100010012Medicaid