Provider Demographics
NPI:1508932583
Name:BIRMINGHAM HEART CLINIC, PC
Entity Type:Organization
Organization Name:BIRMINGHAM HEART CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-815-4810
Mailing Address - Street 1:100 PILOT MEDICAL DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3412
Mailing Address - Country:US
Mailing Address - Phone:205-856-2284
Mailing Address - Fax:205-815-4777
Practice Address - Street 1:100 PILOT MEDICAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3412
Practice Address - Country:US
Practice Address - Phone:205-856-2284
Practice Address - Fax:205-815-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006973174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALCC5229OtherRRMC
AL529602240Medicaid
ALQ341Medicare PIN
ALCC5229OtherRRMC