Provider Demographics
NPI:1629108261
Name:PARK PLACE PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:PARK PLACE PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHAFTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PHD
Authorized Official - Phone:334-356-1417
Mailing Address - Street 1:P.O. BOX 241486
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-1486
Mailing Address - Country:US
Mailing Address - Phone:334-356-1417
Mailing Address - Fax:334-356-1433
Practice Address - Street 1:207 WINTON M. BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117
Practice Address - Country:US
Practice Address - Phone:334-356-1417
Practice Address - Fax:334-356-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2914101YM0800X, 101YP2500X
AL1452101YP2500X
ALD04212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529906980Medicaid
G50487Medicare UPIN
ALG50487Medicare UPIN
AL529906980Medicaid