Provider Demographics
NPI:1912385261
Name:THE UNIVERSITY OF SOUTH ALABAMA FAMILY PRACTICE
Entity Type:Organization
Organization Name:THE UNIVERSITY OF SOUTH ALABAMA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CLINICAL OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:RENETTA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:251-434-3661
Mailing Address - Street 1:3804 CABANA SQ
Mailing Address - Street 2:204
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-7610
Mailing Address - Country:US
Mailing Address - Phone:205-523-1208
Mailing Address - Fax:
Practice Address - Street 1:1504 SPRING HILL AVE
Practice Address - Street 2:1800
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-434-3661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2530261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)