Basic Information
| Provider Information | |||||||||
| NPI: | 1194811901 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRENSHAW COUNTY HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CRENSHAW FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL CIRCLE | ||||||||
| Address2: | |||||||||
| City: | LUVERNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360497344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343353374 | ||||||||
| FaxNumber: | 3343351119 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 ROY BEALL DR | ||||||||
| Address2: | |||||||||
| City: | LUVERNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360496800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343351212 | ||||||||
| FaxNumber: | 3343351217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIMBRO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3343353374 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRENSHAW COUNTY HEALTH CARE AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 540003411 | 05 | AL | MEDICAID | 051518337 | 01 | AL | BC PROVIDER NUMBER | OTHER |