Healthcare Provider Details

I. General information

NPI: 1528075447
Provider Name (Legal Business Name): SOUTHEAST ALABAMA ENT HEAD & NECK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSE CLARK CIRCLE STE 210
DOTHAN AL
36301
US

IV. Provider business mailing address

1118 ROSE CLARK CIRCLE STE 210
DOTHAN AL
36301
US

V. Phone/Fax

Practice location:
  • Phone: 334-702-6900
  • Fax: 334-677-7749
Mailing address:
  • Phone: 334-702-6900
  • Fax: 334-677-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number00025142
License Number StateAL

VIII. Authorized Official

Name: MRS. NANCY P WINDHAM
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 334-702-6900