Provider Demographics
NPI:1700897816
Name:KENNETH MARK MIDDLEBROOKS MD PC
Entity Type:Organization
Organization Name:KENNETH MARK MIDDLEBROOKS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-854-1111
Mailing Address - Street 1:100 PILOT MEDICAL DRIVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3430
Mailing Address - Country:US
Mailing Address - Phone:205-380-0848
Mailing Address - Fax:
Practice Address - Street 1:100 PILOT MEDICAL DRIVE
Practice Address - Street 2:SUITE 125
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3430
Practice Address - Country:US
Practice Address - Phone:205-380-0848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207RI0200X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000089762Medicaid
AL1891742706OtherINDIVIDUAL NPI
AL=========OtherTAX ID
ALC73761Medicare UPIN
AL000089762Medicare PIN
AL000089762Medicaid