Basic Information
| Provider Information | |||||||||
| NPI: | 1326294414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE CARE CENTER OF THE SOUTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91687 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366911687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516026996 | ||||||||
| FaxNumber: | 2516668398 | ||||||||
| Practice Location | |||||||||
| Address1: | 4270 COTTAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366094286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516026996 | ||||||||
| FaxNumber: | 2516668398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOCKHART | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2514632553 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.