=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720350788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISIONSOUTH PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2012
-----------------------------------------------------
Last Update Date | 02/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 HIGHWAY 280 S SUITE 212
-----------------------------------------------------
City | MOUNTAIN BRK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35223-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-879-2221
-----------------------------------------------------
Fax | 205-879-0615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 HIGHWAY 280 S SUITE 212
-----------------------------------------------------
City | MOUNTAIN BRK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35223-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-879-2221
-----------------------------------------------------
Fax | 205-879-0615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. CHARLES MICHAEL ADAMS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 205-879-2221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 15436
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------