1467549634 NPI number — FAMILY & COMMUNITY MEDICINE ASSOCIATES LLC

Table of content: (NPI 1467549634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467549634 NPI number — FAMILY & COMMUNITY MEDICINE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY & COMMUNITY MEDICINE ASSOCIATES LLC
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:
JESS C HAGGERTY III SOLE MBR
Provider Other Organization Name Type Code:
4
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:
1467549634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 EAST BARBOUR STREET
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
EUFAULA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36027-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-687-0250
Provider Business Mailing Address Fax Number:
334-687-0299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 EAST BARBOUR STREET
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EUFAULA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36027-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-687-0250
Provider Business Practice Location Address Fax Number:
334-687-0299
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAGGERTY
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
CORNELIUS
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
334-687-0250

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  24003 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51536749 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009952520 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131642 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51501961 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 63-1271382 . This is a "TRICARE PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51117736 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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