MEDICARE: DYSAUTONOMIA MVP CENTER, LLC.

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	9924	AL
2	207R00000X	Internal Medicine Physician	14740	AL

General Provider Information

NPI Number	:	1518359025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYSAUTONOMIA MVP CENTER, LLC.

Provider Business Mailing Address
First Line	:	2470 ROCKY RIDGE RD
Second Line	:	SUITE 200
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2833
Country	:	US
Telephone Number	:	205-467-4969
Fax Number	:

Provider Business Practice Location Address
First Line	:	2470 ROCKY RIDGE RD
Second Line	:	SUITE 200
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2833
Country	:	US
Telephone Number	:	205-529-5658
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KIMBERLEE F SMITH
Credential	:	CBCS
Telephone Number	:	205-467-4969

Provider Enumeration Date	:	02/21/2015
Last Update Date	:	02/21/2015

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