Healthcare Provider Details

I. General information

NPI: 1083643621
Provider Name (Legal Business Name): PHYSICIAN PROFESSIONAL FEE COMPONENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SIVLEY RD
HUNTSVILLE AL
35801
US

IV. Provider business mailing address

PO BOX 1028
HUNTSVILLE AL
35807
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-8362
  • Fax: 256-533-8262
Mailing address:
  • Phone: 256-533-7064
  • Fax: 256-704-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID A FREDERICK
Title or Position: CHIEF FINANCIAL DIRECTOR
Credential:
Phone: 256-533-8362