Provider Demographics
NPI:1548357916
Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Entity type:Organization
Organization Name:UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/CONTRACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-471-7118
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5842
Mailing Address - Fax:251-470-5809
Practice Address - Street 1:307 UNIVERSITY BLVD N
Practice Address - Street 2:CCCB BLDG. #214
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-3053
Practice Address - Country:US
Practice Address - Phone:251-470-5842
Practice Address - Fax:251-470-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124456Medicaid
AL051054097OtherBCBS
MS09015722Medicaid
FL075487100Medicaid
AL530200801Medicaid
LA1881759Medicaid