Provider Demographics
NPI:1750025060
Name:SOUTHALL, MADELAINE STANBACK
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:STANBACK
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELAINE
Other - Middle Name:ANNE
Other - Last Name:STANBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1900
Mailing Address - Country:US
Mailing Address - Phone:205-638-9589
Mailing Address - Fax:205-638-9977
Practice Address - Street 1:625 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1900
Practice Address - Country:US
Practice Address - Phone:205-638-9589
Practice Address - Fax:205-638-9977
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program