Healthcare Provider Details

I. General information

NPI: 1801240072
Provider Name (Legal Business Name): PMCOA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3283 MALCOLM DR SUITE 100
MONTGOMERY AL
36116-8816
US

IV. Provider business mailing address

PO BOX 660257
BIRMINGHAM AL
35266-0257
US

V. Phone/Fax

Practice location:
  • Phone: 334-356-9970
  • Fax: 334-269-8783
Mailing address:
  • Phone: 205-979-5882
  • Fax: 205-979-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CANDICE W COBB
Title or Position: OWNER
Credential: D.C.
Phone: 334-356-1111