Provider Demographics
NPI:1174643852
Name:AGAPE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:AGAPE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:STIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:205-952-9603
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570
Mailing Address - Country:US
Mailing Address - Phone:205-952-9603
Mailing Address - Fax:205-952-9661
Practice Address - Street 1:1911 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570
Practice Address - Country:US
Practice Address - Phone:205-952-9603
Practice Address - Fax:205-952-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1061751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552982STIMedicaid
ALS91705Medicare UPIN
AL051552982STIMedicaid