Basic Information
| Provider Information | |||||||||
| NPI: | 1700326022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN FAMILY CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AMERICAN FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 CAHABA BEACH RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2054212109 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HOLMES DR | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564033534 | ||||||||
| FaxNumber: | 2564033541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2017 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHANSEN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054038902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN FAMILY CARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | C417 | 01 | AL | MEDICARE PTAN# | OTHER |