Provider Demographics
NPI:1063576858
Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity type:Organization
Organization Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-PIRTLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:205-934-1598
Mailing Address - Street 1:930 20TH ST S
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2610
Mailing Address - Country:US
Mailing Address - Phone:205-934-9700
Mailing Address - Fax:205-975-6962
Practice Address - Street 1:930 20TH ST S
Practice Address - Street 2:SUITE 325
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2610
Practice Address - Country:US
Practice Address - Phone:205-934-9700
Practice Address - Fax:205-975-6962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========048OtherTRICARE
AL=========OtherTAX ID
ALG485Medicare PIN