Healthcare Provider Details

I. General information

NPI: 1598073868
Provider Name (Legal Business Name): BLUE BAYOU SERVICES GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 3RD AVE N
BIRMINGHAM AL
35203-3822
US

IV. Provider business mailing address

2214 3RD AVE N
BIRMINGHAM AL
35203-3822
US

V. Phone/Fax

Practice location:
  • Phone: 205-415-1539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number21413
License Number StateAL

VIII. Authorized Official

Name: MARSHALL SHOEMAKER
Title or Position: CEO
Credential:
Phone: 205-415-1539