Healthcare Provider Details

I. General information

NPI: 1275768178
Provider Name (Legal Business Name): MEDICAL CENTER OTOLARYNGOLOGY CLINIC,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 5TH AVE N SUITE 260
BIRMINGHAM AL
35203-1854
US

IV. Provider business mailing address

1527 5TH AVE N SUITE 260
BIRMINGHAM AL
35203-1854
US

V. Phone/Fax

Practice location:
  • Phone: 205-458-0008
  • Fax: 205-458-0011
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number08026
License Number StateAL

VIII. Authorized Official

Name: RICHARD A. WALKER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 205-458-0008