Basic Information
| Provider Information | |||||||||
| NPI: | 1154362655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPLETE FAMILY MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALABAMA SPECIALITY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350560638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567379416 | ||||||||
| FaxNumber: | 2567365684 | ||||||||
| Practice Location | |||||||||
| Address1: | 1908 CHEROKEE AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350555502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567379416 | ||||||||
| FaxNumber: | 2567365684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2567379416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | X | Managed Care Organizations | Preferred Provider Organization | 208100000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 051507133 | 01 | AL | BLUE CROSS | OTHER | 1366514945 | 01 | NPI | OTHER | 1588603807 | 01 | AL | NPI | OTHER | 080148738 | 01 | AL | RRMC | OTHER | 1235175886 | 01 | AL | NPI | OTHER | 1629093638 | 01 | AL | NPI | OTHER | 009912575 | 05 | AL | MEDICAID | 438170475 | 01 | TRICARE | OTHER |