Provider Demographics
NPI:1649407446
Name:CENTRAL ALABAMA SPINE CENTER
Entity Type:Organization
Organization Name:CENTRAL ALABAMA SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DESHAN
Authorized Official - Middle Name:SHERARD
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:205-655-2277
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-6100
Mailing Address - Country:US
Mailing Address - Phone:205-655-2277
Mailing Address - Fax:205-655-6037
Practice Address - Street 1:52 MEDICAL PARK DR E
Practice Address - Street 2:SUITE 219
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3430
Practice Address - Country:US
Practice Address - Phone:205-655-2277
Practice Address - Fax:205-655-6037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2065111N00000X
AL1151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7009708OtherAETNA
ALP00292774OtherLEGACY
AL1972652865OtherNPI
AL4408799OtherAETNA
AL1215086103OtherNPI
ALP00263210OtherLEGACY
ALP00292774OtherLEGACY
ALP00263210OtherLEGACY
AL1215086103OtherNPI
AL1972652865OtherNPI