Healthcare Provider Details

I. General information

NPI: 1851649321
Provider Name (Legal Business Name): BLUE BAYOU INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SOUTHBRIDGE PKWY
BIRMINGHAM AL
35209-1302
US

IV. Provider business mailing address

2100 SOUTHBRIDGE PKWY
BIRMINGHAM AL
35209-1302
US

V. Phone/Fax

Practice location:
  • Phone: 256-341-7100
  • Fax:
Mailing address:
  • Phone: 256-341-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number1478
License Number StateAL

VIII. Authorized Official

Name: GREGORY MORMAN
Title or Position: CEO
Credential:
Phone: 256-341-7100