Provider Demographics
NPI:1386053783
Name:GMUC OF TILLMANS CORNER
Entity type:Organization
Organization Name:GMUC OF TILLMANS CORNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-633-0123
Mailing Address - Street 1:5100 RANGELINE SERVICE RD N
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-9504
Mailing Address - Country:US
Mailing Address - Phone:251-633-0123
Mailing Address - Fax:251-445-3722
Practice Address - Street 1:5100 RANGELINE SERVICE RD N
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-9504
Practice Address - Country:US
Practice Address - Phone:251-633-0123
Practice Address - Fax:251-445-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty