Healthcare Provider Details

I. General information

NPI: 1740583780
Provider Name (Legal Business Name): UNIVERSITY ORTHOPAEDIC CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1732 TEMPLE AVE N
FAYETTE AL
35555-1321
US

IV. Provider business mailing address

PO BOX 2447
TUSCALOOSA AL
35403-2447
US

V. Phone/Fax

Practice location:
  • Phone: 205-345-0192
  • Fax: 205-247-2194
Mailing address:
  • Phone: 205-345-0192
  • Fax: 205-247-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. DONNA S WOOD
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 205-345-0192