Provider Demographics
NPI:1558410167
Name:NORTHPORT INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:NORTHPORT INTERNAL MEDICINE 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:H
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-339-8282
Mailing Address - Street 1:952 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3363
Mailing Address - Country:US
Mailing Address - Phone:205-339-8282
Mailing Address - Fax:208-339-0936
Practice Address - Street 1:952 ROSE DR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3363
Practice Address - Country:US
Practice Address - Phone:205-339-8282
Practice Address - Fax:208-339-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0410625OtherUNITED HEALTHCARE
ALH018OtherMEDICARE IDENTIFIER
AL528801430Medicaid
AL010021562OtherMEDICARE TRAVELERS
ALC73097Medicare UPIN
AL010021562OtherMEDICARE TRAVELERS