Provider Demographics
NPI:1932533312
Name:JACK D DENVER MD PC
Entity Type:Organization
Organization Name:JACK D DENVER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:DENVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-874-9663
Mailing Address - Street 1:1500 SOUTHLAKE PARK
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3352
Mailing Address - Country:US
Mailing Address - Phone:205-874-9663
Mailing Address - Fax:205-874-9667
Practice Address - Street 1:1500 SOUTHLAKE PARK
Practice Address - Street 2:SUITE 150
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3352
Practice Address - Country:US
Practice Address - Phone:205-874-9663
Practice Address - Fax:205-874-9667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G709374Medicare PIN