Basic Information
| Provider Information | |||||||||
| NPI: | 1801029822 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST ALABAMA REGIONAL HEALTHCARE AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCB FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346887000 | ||||||||
| FaxNumber: | 3346887127 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 RAILROAD STREET | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346887272 | ||||||||
| FaxNumber: | 3346887127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3346887276 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.