Provider Demographics
NPI:1639337934
Name:ENT BESSEMER, LLC
Entity type:Organization
Organization Name:ENT BESSEMER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-481-7780
Mailing Address - Street 1:985 9TH AVE SW
Mailing Address - Street 2:SUITE 308
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-4500
Mailing Address - Country:US
Mailing Address - Phone:205-481-7780
Mailing Address - Fax:205-481-7740
Practice Address - Street 1:985 9TH AVE SW
Practice Address - Street 2:SUITE 308
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-4500
Practice Address - Country:US
Practice Address - Phone:205-481-7780
Practice Address - Fax:205-481-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12109207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1010135OtherUNITED HEALTHCARE
AL51045124OtherBLUE CROSS OF ALABAMA
SC420842449OtherTRICARE
AL529900180Medicaid
SC420842449OtherTRICARE
AL51045124OtherBLUE CROSS OF ALABAMA