Provider Demographics
NPI:1245361120
Name:BHC-DEKALB
Entity type:Organization
Organization Name:BHC-DEKALB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-715-5901
Mailing Address - Street 1:415 MEDICAL CENTER DR SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3421
Mailing Address - Country:US
Mailing Address - Phone:256-997-2820
Mailing Address - Fax:256-997-2890
Practice Address - Street 1:200 BEACON PKWY W
Practice Address - Street 2:SUITE 330
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-3102
Practice Address - Country:US
Practice Address - Phone:205-715-5910
Practice Address - Fax:205-715-5928
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST HEALTH CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD692Medicare ID - Type UnspecifiedMEDICARE GROUP