Provider Demographics
NPI:1720393606
Name:MIBELLA GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:MIBELLA GYNECOLOGY, LLC
Other - Org Name:MIBELLA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-995-1009
Mailing Address - Street 1:2807 GREYSTONE COMMERCIAL BLVD
Mailing Address - Street 2:UNIT 38
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-9601
Mailing Address - Country:US
Mailing Address - Phone:205-995-1009
Mailing Address - Fax:205-995-1049
Practice Address - Street 1:2807 GREYSTONE COMMERCIAL BLVD
Practice Address - Street 2:UNIT 38
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-9601
Practice Address - Country:US
Practice Address - Phone:205-995-1009
Practice Address - Fax:205-995-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27416207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL27416OtherLICENSE
AL1831127083Medicaid