Provider Demographics
NPI:1093853434
Name:PRIMARY CARE CTR OF TUSCALOOSA LLC
Entity Type:Organization
Organization Name:PRIMARY CARE CTR OF TUSCALOOSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-366-9181
Mailing Address - Street 1:1000 FAIRFAX PARK
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2806
Mailing Address - Country:US
Mailing Address - Phone:205-366-9181
Mailing Address - Fax:
Practice Address - Street 1:1000 FAIRFAX PARK
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2806
Practice Address - Country:US
Practice Address - Phone:205-366-9181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21061261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51517558OtherBLUE CROSS BLUE SHIELD
AL51517558OtherBLUE CROSS BLUE SHIELD
AL051517558Medicare ID - Type Unspecified