Provider Demographics
NPI:1558303842
Name:GARDENDALE PHYSICIAN ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:GARDENDALE PHYSICIAN ASSOCIATES, P.C.
Other - Org Name:GARDENDALE INTERNAL MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NOLAN
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-418-1221
Mailing Address - Street 1:2217 DECATUR HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2301
Mailing Address - Country:US
Mailing Address - Phone:205-418-1212
Mailing Address - Fax:205-418-1210
Practice Address - Street 1:2217 DECATUR HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2301
Practice Address - Country:US
Practice Address - Phone:205-418-1212
Practice Address - Fax:205-418-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6626207R00000X
AL12987207R00000X
AL21240207R00000X
AL7130207R00000X
AL171892085R0202X
ALPTH3430225100000X
ALPTH4168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1336195494OtherNPI# AMANDA C. HENDERSON,
ALG94957Medicare UPIN
ALP29080Medicare UPIN
ALQ24657Medicare UPIN
ALF35852Medicare UPIN
ALC73490Medicare UPIN
AL1336195494OtherNPI# AMANDA C. HENDERSON,
ALC73494Medicare UPIN