Provider Demographics
NPI:1023216801
Name:EUFAULA FAMILY MEDICINE
Entity Type:Organization
Organization Name:EUFAULA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-687-0112
Mailing Address - Street 1:617 E BROAD ST
Mailing Address - Street 2:B
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36027
Mailing Address - Country:US
Mailing Address - Phone:334-687-0112
Mailing Address - Fax:334-687-0113
Practice Address - Street 1:617 E BROAD ST
Practice Address - Street 2:B
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027
Practice Address - Country:US
Practice Address - Phone:334-687-0112
Practice Address - Fax:334-687-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH17755Medicare UPIN