Basic Information
| Provider Information | |||||||||
| NPI: | 1235541418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDENDALE SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235022 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343862051 | ||||||||
| FaxNumber: | 3344811200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2213 DECATUR HWY | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054186021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2014 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | ODOM | ||||||||
| AuthorizedOfficialFirstName: | DEIRDRE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3343966930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.