Provider Demographics
NPI:1487629101
Name:ALABAMA SPORTS MEDICINE AND ORTHO CENTER
Entity Type:Organization
Organization Name:ALABAMA SPORTS MEDICINE AND ORTHO CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:H
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:IMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-939-3000
Mailing Address - Street 1:2800 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BHAM
Mailing Address - State:AZ
Mailing Address - Zip Code:35233
Mailing Address - Country:US
Mailing Address - Phone:205-939-3000
Mailing Address - Fax:205-930-0008
Practice Address - Street 1:806 ST VINCENTS DRIVE
Practice Address - Street 2:SUITE 415
Practice Address - City:BHAM
Practice Address - State:AZ
Practice Address - Zip Code:35205
Practice Address - Country:US
Practice Address - Phone:205-939-3000
Practice Address - Fax:205-930-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0310040001OtherCIGNA GOVERNMENT SERVICES
C550Medicare PIN