Healthcare Provider Details

I. General information

NPI: 1083154702
Provider Name (Legal Business Name): UAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 19TH ST S
BIRMINGHAM AL
35249-6914
US

IV. Provider business mailing address

619 19TH ST S
BIRMINGHAM AL
35249-6914
US

V. Phone/Fax

Practice location:
  • Phone: 220-593-4959
  • Fax:
Mailing address:
  • Phone: 220-593-4959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number1-045125
License Number StateAL

VIII. Authorized Official

Name: MS. LISA MARIA BALDONE
Title or Position: FAMILY NURSE PRACTITIONER
Credential: CRNP
Phone: 205-934-9595