=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164582409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIRPACK MEDICAL PROCEDURES, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 PATTON CHAPEL RD SUITE 103
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35216-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-487-1203
-----------------------------------------------------
Fax | 205-487-1205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 DAVIS DR
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35503-8260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-487-1203
-----------------------------------------------------
Fax | 205-487-1205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JILL S TIRPRAC
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 205-487-1203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 20629
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------