Provider Demographics
NPI:1841472529
Name:OBELISK HEALTHCARE
Entity type:Organization
Organization Name:OBELISK HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-558-0262
Mailing Address - Street 1:4705 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3078
Mailing Address - Country:US
Mailing Address - Phone:334-558-0262
Mailing Address - Fax:334-558-0267
Practice Address - Street 1:4705 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3078
Practice Address - Country:US
Practice Address - Phone:334-558-0262
Practice Address - Fax:334-558-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20243261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-21545OtherBCBS ALABAMA
AL529922860Medicaid
AL529922860Medicaid
AL1205803327Medicare PIN