Provider Demographics
NPI:1649789249
Name:ISLAND MEDICAL RED BAY LLC
Entity type:Organization
Organization Name:ISLAND MEDICAL RED BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-656-5911
Mailing Address - Street 1:PO BOX 92974
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-2974
Mailing Address - Country:US
Mailing Address - Phone:877-716-2447
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:211 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:RED BAY
Practice Address - State:AL
Practice Address - Zip Code:35582-3858
Practice Address - Country:US
Practice Address - Phone:256-356-8160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty