Basic Information
| Provider Information | |||||||||
| NPI: | 1477664779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SARALAND FAMILY PRACT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 ENNIS ST | ||||||||
| Address2: | |||||||||
| City: | SARALAND | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365712706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2515442000 | ||||||||
| FaxNumber: | 2515442004 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 ENNIS ST | ||||||||
| Address2: | |||||||||
| City: | SARALAND | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365712706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2515442000 | ||||||||
| FaxNumber: | 2515442004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2515442000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 00012136 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | K961 | 01 | MEDICARE GROUP | OTHER |