Provider Demographics
NPI:1114119567
Name:PHYSICIAN MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:PHYSICIAN MEDICAL CENTER, LLC
Other - Org Name:PHYSICIANS MEDICAL CENTER CARRAWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICESARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-502-6111
Mailing Address - Street 1:PO BOX 10288
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0288
Mailing Address - Country:US
Mailing Address - Phone:205-502-5610
Mailing Address - Fax:205-502-5513
Practice Address - Street 1:1600 CARRAWAY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35234
Practice Address - Country:US
Practice Address - Phone:205-502-5610
Practice Address - Fax:205-502-5513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty