Healthcare Provider Details

I. General information

NPI: 1619473766
Provider Name (Legal Business Name): IMC NORTH BALDWIN PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL CENTER DR
BAY MINETTE AL
36507-4163
US

IV. Provider business mailing address

2002 MEDICAL CENTER DR
BAY MINETTE AL
36507-4163
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-1331
  • Fax:
Mailing address:
  • Phone: 251-435-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY PALAZZO
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 251-435-1331