Provider Demographics
NPI:1952814790
Name:UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY
Other - Org Name:WEST MOBILE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/ACT REP
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-318-2681
Mailing Address - Street 1:3929-1 AIRPORT BLVD
Mailing Address - Street 2:5TH FLOOR, ROOM 513
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609
Mailing Address - Country:US
Mailing Address - Phone:251-318-2681
Mailing Address - Fax:251-378-6222
Practice Address - Street 1:2423 SCHILLINGER RD S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4136
Practice Address - Country:US
Practice Address - Phone:251-660-5950
Practice Address - Fax:251-660-5949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156183Medicaid