Basic Information
| Provider Information | |||||||||
| NPI: | 1366526865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USA HEALTH SERVICES FOUNDATION | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | USA HEALTH SERVICES FOUNDATION LAB OF ANATOMICAL PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 FILLINGIM ST | ||||||||
| Address2: | MOORER BLDG #1119 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514717790 | ||||||||
| FaxNumber: | 2514717715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | TATE | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2514705842 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1502022 | 05 | LA | MEDICAID | 532000601 | 05 | AL | MEDICAID | 690002900 | 01 | AL | RAILROAD MEDICARE PTAN | OTHER | 0110645 | 05 | MS | MEDICAID | 051054096 | 01 | AL | BCBS | OTHER | 075493500 | 05 | FL | MEDICAID |