Healthcare Provider Details

I. General information

NPI: 1972671287
Provider Name (Legal Business Name): VINCENT EDWARD MORTELLARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-9100
  • Fax:
Mailing address:
  • Phone: 205-731-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTRN8848
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number30918
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: