MEDICARE: PROVIDENCE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QL0400X	Lithotripsy Clinic/Center
2	282N00000X	General Acute Care Hospital	10385	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
8	5000060	OTHER		MEDICARE COMPLETE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	025	OTHER	BLUE CROSS
2	166828300	OTHER	US DEPT OF LABOR
3	6120570	OTHER	AETNA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	200020413	OTHER	MS STATE PUBLIC SCHOOLS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	10374	OTHER	HEALTHSPRING
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952390643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HOSPITAL

Provider Business Mailing Address
First Line	:	PO BOX 851537
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36685-1537
Country	:	US
Telephone Number	:	251-633-1600
Fax Number	:	251-633-1679

Provider Business Practice Location Address
First Line	:	6801 AIRPORT BLVD
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36608-3709
Country	:	US
Telephone Number	:	251-633-1600
Fax Number	:	251-633-1679

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MR. TODD S. KENNEDY
Credential	:
Telephone Number	:	251-633-1663

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	09/29/2015

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Directions to “PROVIDENCE HOSPITAL ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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