Provider Demographics
NPI:1629238456
Name:CHILDRENS MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL CENTER
Other - Org Name:PHILLIP M PHILLIPS JR MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-345-2677
Mailing Address - Street 1:1800 RICE MINE RD N
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2383
Mailing Address - Country:US
Mailing Address - Phone:205-345-2677
Mailing Address - Fax:205-345-2679
Practice Address - Street 1:1800 RICE MINE RD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2383
Practice Address - Country:US
Practice Address - Phone:205-345-2677
Practice Address - Fax:205-345-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11958284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL558700000Medicaid
AL16427Medicaid