Provider Demographics
NPI:1922546357
Name:MEDCENTER PRIMARY CARE, LLC
Entity type:Organization
Organization Name:MEDCENTER PRIMARY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-756-2273
Mailing Address - Street 1:4960 RICE MINE ROAD NE
Mailing Address - Street 2:STE 10
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-2838
Mailing Address - Country:US
Mailing Address - Phone:205-333-9467
Mailing Address - Fax:057-581-6562
Practice Address - Street 1:4960 RICE MINE ROAD NE
Practice Address - Street 2:STE 10
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-2838
Practice Address - Country:US
Practice Address - Phone:205-333-9467
Practice Address - Fax:205-758-1656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AL9381261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty