Healthcare Provider Details

I. General information

NPI: 1568864494
Provider Name (Legal Business Name): UNIVERSITY OF MONTEVALLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 03/05/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 COLLEGE DR STATION 6060
MONTEVALLO AL
35115-3732
US

IV. Provider business mailing address

75 COLLEGE DR STATION 6602
MONTEVALLO AL
35115-3732
US

V. Phone/Fax

Practice location:
  • Phone: 205-665-6602
  • Fax: 205-665-6614
Mailing address:
  • Phone: 205-665-6602
  • Fax: 205-665-6614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MAUREN GREGORY
Title or Position: HEAD ATHLETIC TRAINER
Credential: LAT ATC
Phone: 205-665-6602