Provider Demographics
NPI:1902000102
Name:PROVIDENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE SERVICES
Other - Org Name:PROVIDENCE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHRISTIANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-631-3574
Mailing Address - Street 1:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:19140 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-2306
Practice Address - Country:US
Practice Address - Phone:251-866-0086
Practice Address - Fax:251-866-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907120Medicaid
AL529907120Medicaid