Healthcare Provider Details

I. General information

NPI: 1275828659
Provider Name (Legal Business Name): IMC OTOLARYNGOLOGY FACIAL PLASTIC & RECONSTRUCTIVE SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 MEDICAL PARK DR BLDG 1, SUITE 103
MOBILE AL
36693-3318
US

IV. Provider business mailing address

3401 MEDICAL PARK DR BLDG 1, SUITE 103
MOBILE AL
36693-3318
US

V. Phone/Fax

Practice location:
  • Phone: 251-463-2010
  • Fax:
Mailing address:
  • Phone: 251-463-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIANNE F SMITH
Title or Position: DIRECTOR
Credential:
Phone: 251-463-2010