Healthcare Provider Details

I. General information

NPI: 1831728799
Provider Name (Legal Business Name): WEST ALABAMA AIDS OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 STARK RD
STARKVILLE MS
39759-3613
US

IV. Provider business mailing address

2720 6TH ST
TUSCALOOSA AL
35401-1731
US

V. Phone/Fax

Practice location:
  • Phone: 205-759-8470
  • Fax:
Mailing address:
  • Phone: 205-759-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE HAWTHORNE
Title or Position: CREDENTIALING COORDINATOR
Credential: MS
Phone: 205-292-2428