Provider Demographics
NPI:1437294642
Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:MOBILE DIV - BUREAU OF CLINICAL LABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTH SYSTEMS
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-206-5061
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-9901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 MUSEUM DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1939
Practice Address - Country:US
Practice Address - Phone:251-344-6049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL01D0641761291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910480Medicaid