Healthcare Provider Details

I. General information

NPI: 1427041441
Provider Name (Legal Business Name): USAF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLD 760 MAXWELL AFB CLINIC
MONTGOMERY AL
36117
US

IV. Provider business mailing address

728 SUMMER LN
PRATTVILLE AL
36066-6161
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-1126
  • Fax:
Mailing address:
  • Phone: 210-393-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number1068201
License Number StateAL

VIII. Authorized Official

Name: WAYNE SHERIDAN COX
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 210-393-2465