1376211011 NPI number — PHYSICIANS CARE OF CLARKE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376211011 NPI number — PHYSICIANS CARE OF CLARKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS CARE OF CLARKE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376211011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24B CAMDEN BYP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36726-1770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-882-1919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-636-4823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
FARRELL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
334-636-5311

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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