Healthcare Provider Details

I. General information

NPI: 1063576858
Provider Name (Legal Business Name): UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 20TH ST S SUITE 325
BIRMINGHAM AL
35205-2610
US

IV. Provider business mailing address

930 20TH ST S SUITE 325
BIRMINGHAM AL
35205-2610
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-9700
  • Fax: 205-975-6962
Mailing address:
  • Phone: 205-934-9700
  • Fax: 205-975-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. TYRA JOHNSON-PIRTLE
Title or Position: ADMINISTRATOR
Credential: C.P.A
Phone: 205-934-1598