Basic Information
| Provider Information | |||||||||
| NPI: | 1154972883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HEALTH CARE AUTHORITY OF THE CITY OF EUFAULA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 820 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346887451 | ||||||||
| FaxNumber: | 3346887423 | ||||||||
| Practice Location | |||||||||
| Address1: | 512 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | HURTSBORO | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342326551 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2019 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUNNINGHAM | ||||||||
| AuthorizedOfficialFirstName: | JULIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC OPERATIONS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3346887451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE HEALTH CARE AUTHORITY OF THE CITY OF EUFAULA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA, MSHA, CMPE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.