Provider Demographics
NPI:1740583780
Name:UNIVERSITY ORTHOPAEDIC CLINIC, PC
Entity Type:Organization
Organization Name:UNIVERSITY ORTHOPAEDIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-345-0192
Mailing Address - Street 1:PO BOX 2447
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2447
Mailing Address - Country:US
Mailing Address - Phone:205-345-0192
Mailing Address - Fax:205-247-2194
Practice Address - Street 1:1732 TEMPLE AVE N
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1321
Practice Address - Country:US
Practice Address - Phone:205-345-0192
Practice Address - Fax:205-247-2194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY ORTHOPAEDIC CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51036272OtherBLUE CROSS BLUE SHIELD
AL528301220Medicaid
AL51036272OtherBLUE CROSS BLUE SHIELD