Healthcare Provider Details

I. General information

NPI: 1093852329
Provider Name (Legal Business Name): MAX BLANE BULLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BAPITIST MEDICAL CENTER SOUTH,2105 EAST SOUTH BOULEVARD
MONTGOMERY AL
38111-0010
US

IV. Provider business mailing address

144 CANTER WAY
ALABASTER AL
35007-7610
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-2100
  • Fax:
Mailing address:
  • Phone: 205-621-5240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-054439
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: