Basic Information
| Provider Information | |||||||||
| NPI: | 1669783791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CULLMAN PRIMARY CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 AL HIGHWAY 157 STE 203 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350580600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567365505 | ||||||||
| FaxNumber: | 2567365185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1912 CHEROKEE AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350555595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567341012 | ||||||||
| FaxNumber: | 2567393450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | HICE | ||||||||
| AuthorizedOfficialFirstName: | SHANA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MGR | ||||||||
| AuthorizedOfficialTelephone: | 2567365505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CULLMAN PRIMARY CARE, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 529916590 | 05 | AL | MEDICAID |