Basic Information
| Provider Information | |||||||||
| NPI: | 1982910089 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN FAMILY CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMERICAN FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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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: | 2604 HIGHWAY 31 S | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356031506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564453050 | ||||||||
| FaxNumber: | 2564453053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2010 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHANSEN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054212102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN FAMILY CARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | C417 | 01 | AL | BCBS COMMON IDENTIFIER | OTHER |