Provider Demographics
NPI:1023143484
Name:BHC-BLOUNT & ETOWAH COUNTIES
Entity type:Organization
Organization Name:BHC-BLOUNT & ETOWAH COUNTIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INTEGRATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-715-5415
Mailing Address - Street 1:PO BOX 13128
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-3128
Mailing Address - Country:US
Mailing Address - Phone:205-715-5904
Mailing Address - Fax:205-715-5928
Practice Address - Street 1:180 MEDICAL STREET
Practice Address - Street 2:
Practice Address - City:SNEAD
Practice Address - State:AL
Practice Address - Zip Code:35952
Practice Address - Country:US
Practice Address - Phone:205-466-7114
Practice Address - Fax:205-466-3350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST HEALTH CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541003888Medicaid
AL529301940Medicaid
AL013888Medicare ID - Type UnspecifiedRHC PROVIDER #
AL541003888Medicaid
ALD729Medicare PIN