Basic Information
| Provider Information | |||||||||
| NPI: | 1982685178 | ||||||||
| 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: | 2567391759 | ||||||||
| FaxNumber: | 2567390027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 AL HIGHWAY 157 STE 204 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350581273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567343141 | ||||||||
| FaxNumber: | 2567343866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOSTICK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2567343141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 291U00000X | 01D0300133 | AL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 000040933 | 05 | AL | MEDICAID | 000040933 | 01 | AL | MEDICARE GROUP ID | OTHER |