Provider Demographics
NPI:1255447124
Name:JOHN WIDEMAN, MD, PC
Entity type:Organization
Organization Name:JOHN WIDEMAN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-877-1000
Mailing Address - Street 1:2006 BROOKWOOD MEDICAL CTR DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6899
Mailing Address - Country:US
Mailing Address - Phone:205-877-1000
Mailing Address - Fax:
Practice Address - Street 1:2006 BROOKWOOD MEDICAL CTR DR
Practice Address - Street 2:SUITE 214
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6899
Practice Address - Country:US
Practice Address - Phone:205-877-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherEIN
AL=========OtherEIN