Provider Demographics
NPI:1740576610
Name:ALABAMA SPORTS, SPINE & OCCUPATIONAL MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:ALABAMA SPORTS, SPINE & OCCUPATIONAL MEDICINE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DONIAL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-350-2208
Mailing Address - Street 1:242 WINTON BLOUNT LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 WINTON BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3501
Practice Address - Country:US
Practice Address - Phone:319-350-2208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty