Provider Demographics
NPI:1770534901
Name:MONTGOMERY BAPTIST OUTREACH SERVICES CORPORATION
Entity type:Organization
Organization Name:MONTGOMERY BAPTIST OUTREACH SERVICES CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BRUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-273-4258
Mailing Address - Street 1:4371 NARROW LANE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2971
Mailing Address - Country:US
Mailing Address - Phone:334-613-3680
Mailing Address - Fax:334-613-3685
Practice Address - Street 1:4371 NARROW LANE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2971
Practice Address - Country:US
Practice Address - Phone:334-613-3680
Practice Address - Fax:334-613-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0113048OtherUNITED HEALTHCARE
ALCC9180OtherRAILROAD MEDICARE
AL529904250Medicaid
AL=========OtherCHAMPUS
AL529904250Medicaid
ALCC9180OtherRAILROAD MEDICARE
AL=========OtherWORK COMP
AL529904250Medicaid