Provider Demographics
NPI:1093324287
Name:PRESTIGE TELEMEDICINE GROUP LLC
Entity Type:Organization
Organization Name:PRESTIGE TELEMEDICINE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:FAGGARD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:251-610-4188
Mailing Address - Street 1:1008 RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4231
Mailing Address - Country:US
Mailing Address - Phone:251-517-4411
Mailing Address - Fax:
Practice Address - Street 1:303 CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3442
Practice Address - Country:US
Practice Address - Phone:251-517-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty