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General NPI Number Information
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NPI Number | 1083643621
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Entity Type | Organization
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Legal Business Name | PHYSICIAN PROFESSIONAL FEE COMPONENT
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 101 SIVLEY RD
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City | HUNTSVILLE
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State | AL
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Zip | 35801
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Country | US
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Telephone | 256-533-8362
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Fax | 256-533-8262
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Provider Business Mailing Address
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Address Line | PO BOX 1028
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City | HUNTSVILLE
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State | AL
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Zip | 35807
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Country | US
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Telephone | 256-533-7064
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Fax | 256-704-0115
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Authorized Official
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Title or Position | CHIEF FINANCIAL DIRECTOR
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Name | DAVID A FREDERICK
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Credential |
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Telephone | 256-533-8362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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