1104126739 NPI number — FAMILY MEDICINE OF TUSCALOOSA, LLC

Table of content: (NPI 1104126739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104126739 NPI number — FAMILY MEDICINE OF TUSCALOOSA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE OF TUSCALOOSA, 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:
Provider Other Organization Name Type Code:
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:
1104126739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 TOWNCENTER BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35406-1833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-464-4971
Provider Business Mailing Address Fax Number:
205-343-7425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 TOWNCENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35406-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-464-4971
Provider Business Practice Location Address Fax Number:
205-343-7425
Provider Enumeration Date:
10/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
AMMAN
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
205-464-4971

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  24343 , 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)





Copyright © 2007-2025 www.npivalidator.com