Provider Demographics
NPI:1750197794
Name:OLIVE BRANCH DERMATOLOGY LLC
Entity type:Organization
Organization Name:OLIVE BRANCH DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMENA
Authorized Official - Middle Name:RAJA
Authorized Official - Last Name:ALKESWANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-504-5883
Mailing Address - Street 1:PO BOX 36263
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35236-6263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4721 CHACE CIR
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3700
Practice Address - Country:US
Practice Address - Phone:205-266-9011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty