Provider Demographics
NPI:1447291190
Name:MEDICAL PARK OBGYN PC
Entity type:Organization
Organization Name:MEDICAL PARK OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-928-1222
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533
Mailing Address - Country:US
Mailing Address - Phone:251-928-1222
Mailing Address - Fax:251-928-2398
Practice Address - Street 1:150 SOUTH INGLESIDE AVE
Practice Address - Street 2:STE 6
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532
Practice Address - Country:US
Practice Address - Phone:251-928-1222
Practice Address - Fax:251-928-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528401340Medicaid
ALD533Medicare ID - Type Unspecified