=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881182236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERFACE MEDICAL CONSULTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2018
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12141 CRI
-----------------------------------------------------
City | FAIRHOPE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-689-7168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 146
-----------------------------------------------------
City | FAIRHOPE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36533-0146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-689-7168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALISTS
-----------------------------------------------------
Name | STEPHANIE INGENITO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-352-3063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------