| Name: | Edwards Lake Medical Center, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 21 Feb 2003 (22 years ago) |
| Entity Number: | 000-688-312 |
| Register Number: | 000688312 |
| County: | Jefferson |
| Place of Formation: | Jefferson County |
| Principal Address: | BIRMINGHAM, AL |
| Registered Office Street Address: | 3240 EDWARDS LAKE PKWY STE 200BIRMINGHAM, AL 35235 |
| Registered Office Street Address ZIP Code: | 35235 |
Activities
OWN/OPERATE/MANAGE A MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1043321300 | 2006-08-31 | 2024-06-20 | 3240 EDWARDS LAKE PKWY, SUITE 204, BIRMINGHAM, AL, 352353117, US | 3240 EDWARDS LAKE PKWY, SUITE 204, BIRMINGHAM, AL, 352353117, US | |||||||||||||||||||||||||
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| Phone | +1 205-949-1414 |
| Fax | 2059491415 |
Authorized person
| Name | JACKI BAILEY |
| Role | BILLING MGR |
| Phone | 2056991632 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 00013482 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | INDIVIDUAL NPI |
| Number | 1316985062 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| MADDUX, ANDREAS T | Agent | 3093 STERLING ROADBIRMINGHAM, AL 35213-3503 |
| Name | Role | Address |
|---|---|---|
| MADDUX, ANDREAS T | Member | 3093 STERLING ROADBIRMINGHAM, AL 35213-3503 |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
