Provider Demographics
NPI:1053182055
Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity type:Organization
Organization Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:JACQUISELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-934-5088
Mailing Address - Street 1:2826 ROSS CLARK CIR STE 305
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2017
Mailing Address - Country:US
Mailing Address - Phone:334-305-3290
Mailing Address - Fax:334-305-3310
Practice Address - Street 1:2826 ROSS CLARK CIR STE 305
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2017
Practice Address - Country:US
Practice Address - Phone:334-305-3290
Practice Address - Fax:334-305-3310
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty