Provider Demographics
NPI:1700278777
Name:MONTGOMERY AREA PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:MONTGOMERY AREA PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BABATUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-318-0044
Mailing Address - Street 1:2430 FAIRLANE DR
Mailing Address - Street 2:SUITE C-07
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2430 FAIRLANE DR
Practice Address - Street 2:SUITE C-07
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1642
Practice Address - Country:US
Practice Address - Phone:334-318-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25622261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI16556Medicare UPIN