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General NPI Number Information
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NPI Number | 1912385261
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Entity Type | Organization
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Legal Business Name | THE UNIVERSITY OF SOUTH ALABAMA FAMILY PRACTICE
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Dates
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Enumeration Date | 05/07/2015
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Last Update Date | 05/07/2015
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Provider Practice Location Address
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Address Line | 1504 SPRING HILL AVE 1800
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City | MOBILE
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State | AL
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Zip | 36604-3207
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Country | US
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Telephone | 251-434-3661
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Fax |
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Provider Business Mailing Address
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Address Line | 3804 CABANA SQ 204
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City | MOBILE
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State | AL
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Zip | 36609-7610
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Country | US
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Telephone | 205-523-1208
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Fax |
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Authorized Official
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Title or Position | MANAGER CLINICAL OPERATION
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Name | RENETTA DENISE MACMILLAN
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Credential | RN
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Telephone | 251-434-3661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | 2530
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License Number State | AL
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