Basic Information
| Provider Information | |||||||||
| NPI: | 1952805400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPSTONE HEALTH SERVICES FOUNDATION PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY MEDICAL CENTER DEMOPOLIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 PETER BRYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354017457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053481770 | ||||||||
| FaxNumber: | 2053481772 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 US HIGHWAY 80 E STE 215 | ||||||||
| Address2: | |||||||||
| City: | DEMOPOLIS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367323605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346548081 | ||||||||
| FaxNumber: | 3346548431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAWTHORNE | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2053481262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.