Healthcare Provider Details

I. General information

NPI: 1386848356
Provider Name (Legal Business Name): PROVIDENCE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD SUITE A101
MOBILE AL
36608-6705
US

IV. Provider business mailing address

PO BOX 850489
MOBILE AL
36685-0489
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-8880
  • Fax: 251-633-2817
Mailing address:
  • Phone: 251-342-3964
  • Fax: 251-631-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CLARK P. CHRISTIANSON
Title or Position: PRESIDENT
Credential:
Phone: 251-633-1660