Provider Demographics
NPI:1962455881
Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:S
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-470-5842
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5842
Mailing Address - Fax:251-470-5809
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:MASTIN BLDG. 617
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-470-5842
Practice Address - Fax:251-470-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALGSD600Medicaid
LA1445061Medicaid
ALF882OtherBCBS COMMON PAY #
LA1445061Medicaid
GACA3952Medicare ID - Type UnspecifiedPGBA RAILROAD
ALG723/G725/G726/G727Medicare PIN
ALF882OtherBCBS COMMON PAY #
ALG724Medicare ID - Type Unspecified
AL=========OtherEIN
LA1445061Medicaid
ALE693/E696Medicare PIN