Provider Demographics
NPI:1033354477
Name:REFORM MEDICAL CLINIC
Entity type:Organization
Organization Name:REFORM MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICARL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-375-6251
Mailing Address - Street 1:514 10TH AVENUE SOUTH WEST
Mailing Address - Street 2:
Mailing Address - City:REFORM
Mailing Address - State:AL
Mailing Address - Zip Code:35481-0670
Mailing Address - Country:US
Mailing Address - Phone:205-375-6251
Mailing Address - Fax:205-375-9064
Practice Address - Street 1:514 10TH AVENUE SOUTH WEST
Practice Address - Street 2:
Practice Address - City:REFORM
Practice Address - State:AL
Practice Address - Zip Code:35481-0670
Practice Address - Country:US
Practice Address - Phone:205-375-6251
Practice Address - Fax:205-375-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11725146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL080138169OtherPALMETTO GBA
AL051076801OtherBLUECROSS BLUE SHIELD OF ALABAMA
AL000084188Medicaid
AL000084188Medicaid
ALC72743Medicare UPIN