Healthcare Provider Details

I. General information

NPI: 1093896466
Provider Name (Legal Business Name): EASTERN NEPHROLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 HUFFMAN ROAD
BIRMINGHAM AL
35215
US

IV. Provider business mailing address

1524 HUFFMAN ROAD
BIRMINGHAM AL
35215
US

V. Phone/Fax

Practice location:
  • Phone: 205-856-0011
  • Fax: 205-856-0726
Mailing address:
  • Phone: 205-856-0011
  • Fax: 205-856-0726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00007283
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0007283
License Number StateAL

VIII. Authorized Official

Name: MS. KELLY F AMERSON
Title or Position: BILLING
Credential:
Phone: 205-856-0011