=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659352193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANK B. FONDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 BISHOP LN N
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-479-4767
-----------------------------------------------------
Fax | 251-476-0116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70187
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36670-1187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-479-4767
-----------------------------------------------------
Fax | 251-476-0116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. FRANK B FONDREN III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 251-479-4767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 10207
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------