Provider Demographics
NPI:1083192173
Name:SHOALS INFECTIOUS DISEASE CONSULTANTS LLC
Entity Type:Organization
Organization Name:SHOALS INFECTIOUS DISEASE CONSULTANTS LLC
Other - Org Name:ST. VINCENT INFECTIOUS DISEASE AND INTERNAL MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:HILAIRE
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-444-4401
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630
Mailing Address - Country:US
Mailing Address - Phone:256-444-4401
Mailing Address - Fax:
Practice Address - Street 1:22281 US HIGHWAY 72 STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2601
Practice Address - Country:US
Practice Address - Phone:256-444-4401
Practice Address - Fax:256-444-4403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
180531025163WW0000X
MD.36985207R00000X, 207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL219543Medicaid