Provider Demographics
NPI:1194789172
Name:SOUTHEASTERN DERMATOLOGY CENTERS
Entity type:Organization
Organization Name:SOUTHEASTERN DERMATOLOGY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INTEGRATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:G.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-715-5415
Mailing Address - Street 1:PO BOX 13128
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-3128
Mailing Address - Country:US
Mailing Address - Phone:205-715-5904
Mailing Address - Fax:205-715-5928
Practice Address - Street 1:817 PRINCETON AVE SW
Practice Address - Street 2:POB II, SUITE 302
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1333
Practice Address - Country:US
Practice Address - Phone:205-781-6995
Practice Address - Fax:205-781-8783
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST HEALTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-14
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529904550Medicaid
AL529904550Medicaid