Healthcare Provider Details

I. General information

NPI: 1275687766
Provider Name (Legal Business Name): JAN E MATHISEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 ELMER J BISSELL RD SUITE C
BIRMINGHAM AL
35243-2941
US

IV. Provider business mailing address

1940 ELMER J BISSELL RD SUITE C
BIRMINGHAM AL
35243-2941
US

V. Phone/Fax

Practice location:
  • Phone: 205-638-5860
  • Fax: 205-638-5879
Mailing address:
  • Phone: 205-638-5860
  • Fax: 205-638-5879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11165
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number11165
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: