Healthcare Provider Details

I. General information

NPI: 1720393606
Provider Name (Legal Business Name): MIBELLA GYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 GREYSTONE COMMERCIAL BLVD UNIT 38
BIRMINGHAM AL
35242-9601
US

IV. Provider business mailing address

2807 GREYSTONE COMMERCIAL BLVD UNIT 38
BIRMINGHAM AL
35242-9601
US

V. Phone/Fax

Practice location:
  • Phone: 205-995-1009
  • Fax: 205-995-1049
Mailing address:
  • Phone: 205-995-1009
  • Fax: 205-995-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number27416
License Number StateAL

VIII. Authorized Official

Name: MIA T COWAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 205-995-1009