Provider Demographics
NPI:1710299425
Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity Type:Organization
Organization Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Other - Org Name:CIVITAN-SPARKS CLINICS ALL-KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE-GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-934-1055
Mailing Address - Street 1:1530 3RD AVE S
Mailing Address - Street 2:CH19 307
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-2041
Mailing Address - Country:US
Mailing Address - Phone:205-934-5471
Mailing Address - Fax:205-975-2380
Practice Address - Street 1:930 20TH ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2610
Practice Address - Country:US
Practice Address - Phone:205-934-5471
Practice Address - Fax:205-975-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-10
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty