Provider Demographics
NPI:1417063637
Name:MOBILE OBSTETRICS AND GYNECOLOGY PC
Entity type:Organization
Organization Name:MOBILE OBSTETRICS AND GYNECOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-0793
Mailing Address - Street 1:6701 AIRPORT BLVD STE B321
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6703
Mailing Address - Country:US
Mailing Address - Phone:251-633-0793
Mailing Address - Fax:251-633-0736
Practice Address - Street 1:6701 AIRPORT BLVD STE B321
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6703
Practice Address - Country:US
Practice Address - Phone:251-633-0793
Practice Address - Fax:251-633-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF789OtherBCBS-AL NUMBER
AL528301400Medicaid
AL207V00000XOtherTAXONOMY CODE