MEDICARE: PROVIDENCE HEALTHCARE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215214283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTHCARE SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 850489
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36685-0489
Country	:	US
Telephone Number	:	251-342-3949
Fax Number	:	251-631-3361

Provider Business Practice Location Address
First Line	:	5100 RANGELINE ROAD NORTH
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36619-9504
Country	:	US
Telephone Number	:	251-378-4000
Fax Number	:	251-378-4006

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CLARK P. CHRISTIANSON
Credential	:
Telephone Number	:	251-631-3574

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	09/13/2012

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Directions to “PROVIDENCE HEALTHCARE SERVICES ” Practice Location

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