Healthcare Provider Details

I. General information

NPI: 1528084787
Provider Name (Legal Business Name): ORTHOPAEDIC AND SPORTS MEDICINE OF MOBILE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD D146
MOBILE AL
36608-6705
US

IV. Provider business mailing address

6701 AIRPORT BLVD D146
MOBILE AL
36608-6705
US

V. Phone/Fax

Practice location:
  • Phone: 251-639-7283
  • Fax: 251-639-7460
Mailing address:
  • Phone: 251-639-7283
  • Fax: 251-639-7460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number13229
License Number StateAL

VIII. Authorized Official

Name: MS. WENDY A STUCKEY
Title or Position: BILLING MANAGER
Credential:
Phone: 251-631-3004