Healthcare Provider Details

I. General information

NPI: 1235541418
Provider Name (Legal Business Name): GARDENDALE SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 DECATUR HWY
GARDENDALE AL
35071-2301
US

IV. Provider business mailing address

PO BOX 235022
MONTGOMERY AL
36123-5022
US

V. Phone/Fax

Practice location:
  • Phone: 205-418-6021
  • Fax:
Mailing address:
  • Phone: 334-386-2051
  • Fax: 334-481-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEIRDRE ODOM
Title or Position: MANAGER
Credential:
Phone: 334-396-6930