Basic Information
| Provider Information | |||||||||
| NPI: | 1730158544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHATOM PRIMARY CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1237 | ||||||||
| Address2: | |||||||||
| City: | CHATOM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518476262 | ||||||||
| FaxNumber: | 2518476277 | ||||||||
| Practice Location | |||||||||
| Address1: | 14634 SAINT STEPHENS AVE | ||||||||
| Address2: | |||||||||
| City: | CHATOM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365186711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518476262 | ||||||||
| FaxNumber: | 2518476277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | DONALD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2518476262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 529905180 | 05 | AL | MEDICAID | 541003923 | 05 | AL | MEDICAID |