Healthcare Provider Details

I. General information

NPI: 1497959613
Provider Name (Legal Business Name): PROVIDENCE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 COTTAGE HILL RD
MOBILE AL
36609-4210
US

IV. Provider business mailing address

PO BOX 850489
MOBILE AL
36685-0489
US

V. Phone/Fax

Practice location:
  • Phone: 251-666-2439
  • Fax: 251-666-3166
Mailing address:
  • Phone: 251-342-3949
  • Fax: 251-631-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD KENNEDY
Title or Position: PRESIDENT
Credential:
Phone: 251-631-3574