Healthcare Provider Details

I. General information

NPI: 1356416879
Provider Name (Legal Business Name): EASTERNSHORE OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8552 MORPHY AVE
FAIRHOPE AL
36532-3696
US

IV. Provider business mailing address

PO BOX 1134
FAIRHOPE AL
36533-1134
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-4113
  • Fax: 251-928-7177
Mailing address:
  • Phone: 251-928-4113
  • Fax: 251-928-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MITZI M CHILDS
Title or Position: PHYSICIAN
Credential: MD
Phone: 251-928-4113