Basic Information
| Provider Information | |||||||||
| NPI: | 1326368853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CULLMAN PRIMARY CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567390801 | ||||||||
| FaxNumber: | 2567390027 | ||||||||
| Practice Location | |||||||||
| Address1: | 4208B EVA RD | ||||||||
| Address2: | |||||||||
| City: | EVA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356217629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567965260 | ||||||||
| FaxNumber: | 2567964639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | HICE | ||||||||
| AuthorizedOfficialFirstName: | SHANA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2567365505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CULLMAN PRIMARY CARE, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 113169 | 05 | AL | MEDICAID |