Healthcare Provider Details

I. General information

NPI: 1386053783
Provider Name (Legal Business Name): GMUC OF TILLMANS CORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 RANGELINE SERVICE RD N
MOBILE AL
36619-9504
US

IV. Provider business mailing address

5100 RANGELINE SERVICE RD N
MOBILE AL
36619-9504
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-0123
  • Fax: 251-445-3722
Mailing address:
  • Phone: 251-633-0123
  • Fax: 251-445-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DARREN WATERS
Title or Position: PARTNER
Credential: MD
Phone: 251-633-0123