Basic Information
| Provider Information | |||||||||
| NPI: | 1992711303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN FAMILY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2147 RIVERCHASE OFFICE ROAD | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2059820278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2936 MARTI LANE | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342880088 | ||||||||
| FaxNumber: | 3342882071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHANSEN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054212101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN FAMILY CARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | CA6570 | 01 | AL | RAILROAD MEDICARE | OTHER |