=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063457919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA ORAL SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 GRELOT RD BUILDING C
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-344-6191
-----------------------------------------------------
Fax | 251-344-6794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901 GRELOT RD BUILDING C
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-344-6191
-----------------------------------------------------
Fax | 251-344-6794
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. JEANNE MARZULLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-344-6191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4598
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5437
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 3814
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------