Provider Demographics
NPI:1952390643
Name:PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-1663
Mailing Address - Street 1:PO BOX 851537
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-1537
Mailing Address - Country:US
Mailing Address - Phone:251-633-1600
Mailing Address - Fax:251-633-1679
Practice Address - Street 1:6801 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3709
Practice Address - Country:US
Practice Address - Phone:251-633-1600
Practice Address - Fax:251-633-1679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QL0400X
AL10385282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
025OtherBLUE CROSS
166828300OtherUS DEPT OF LABOR
6120570OtherAETNA
MS00220487Medicaid
200020413OtherMS STATE PUBLIC SCHOOLS
ALH0S0090HMedicaid
10374OtherHEALTHSPRING
5000060OtherMEDICARE COMPLETE
200020413OtherMS STATE PUBLIC SCHOOLS