Basic Information
| Provider Information | |||||||||
| NPI: | 1790006203 | ||||||||
| 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: | 16356 HWY 41 NORTH | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567471186 | ||||||||
| FaxNumber: | 2567471196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2010 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2567390801 | ||||||||
| 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 | 106952 | 05 | AL | MEDICAID |