Provider Demographics
NPI:1700215894
Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Other - Org Name:PROVIDENCE MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-1660
Mailing Address - Street 1:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:19140 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-2306
Practice Address - Country:US
Practice Address - Phone:251-866-0086
Practice Address - Fax:251-866-0089
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALABAMA PROVIDENCE HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-08
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty