Provider Demographics
NPI:1245485267
Name:UNIVERSITY OF SOUTH ALABAMA
Entity type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-460-7681
Mailing Address - Street 1:307 N UNIVERSITY BLVD
Mailing Address - Street 2:TRP BLDG 3, SUITE 1175
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36688-3053
Mailing Address - Country:US
Mailing Address - Phone:251-414-8101
Mailing Address - Fax:251-414-8227
Practice Address - Street 1:307 N UNIVERSITY BLVD
Practice Address - Street 2:TRP BLDG 3, SUITE 1175
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-3053
Practice Address - Country:US
Practice Address - Phone:251-414-8101
Practice Address - Fax:251-414-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care