Basic Information
| Provider Information | |||||||||
| NPI: | 1376266726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE LAKE HEALTH ALABAMA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3104 BLUE LAKE DR STE 110 | ||||||||
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| City: | VESTAVIA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352432372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059771949 | ||||||||
| FaxNumber: | 2059771933 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 HELTON CT | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356301464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567600672 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PATRICK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2059771949 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.