Organization
PHYSICIAN PROFESSIONAL FEE COMPONENT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID A FREDERICK (CHIEF FINANCIAL DIRECTOR)
(256) 533-8362
Entity
Organization
Contact information
Practice address
101 SIVLEY RD, HUNTSVILLE, AL 35801
(256) 533-8362
(256) 533-8262
Mailing address
PO BOX 1028, HUNTSVILLE, AL 35807
(256) 533-7064
(256) 704-0115
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
207RC0000X
Cardiovascular Disease Physician
—
—
207RP1001X
Pulmonary Disease Physician
—
—
2084N0400X
Neurology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CH7560
RAILROAD MEDICARE
AL
01
—
F956
BLUE CROSS OF ALABAMA
AL
Enumeration date
07/03/2006
Last updated
07/16/2007
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