Healthcare Provider Details

I. General information

NPI: 1093316259
Provider Name (Legal Business Name): UNIVERSITY OF SOUTH ALABAMA HEALTH CARE AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 04/08/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 OLD SHELL RD
MOBILE AL
36607-3021
US

IV. Provider business mailing address

3929-1 AIRPORT BLVD 5TH FLOOR, ROOM 513
MOBILE AL
36609
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-6400
  • Fax: 251-660-6401
Mailing address:
  • Phone: 251-318-2681
  • Fax: 251-378-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICA MADISON
Title or Position: CREDENTIALING
Credential:
Phone: 251-318-2681