Provider Demographics
NPI:1508878083
Name:PROVIDENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE SERVICES
Other - Org Name:PROVIDENCE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHRISTIANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-1660
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 1:6701 AIRPORT BLVD
Practice Address - Street 2:SUITE D430
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6705
Practice Address - Country:US
Practice Address - Phone:251-342-3949
Practice Address - Fax:251-631-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty