Provider Demographics
NPI:1447799861
Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Other - Org Name:PROVIDENCE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-342-3949
Mailing Address - Street 1:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:5621 COTTAGE HILL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-4210
Practice Address - Country:US
Practice Address - Phone:251-666-2439
Practice Address - Fax:251-666-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156183Medicaid
AL156183Medicaid