Provider Demographics
NPI:1225082951
Name:TRIAD OF ALABAMA LLC
Entity Type:Organization
Organization Name:TRIAD OF ALABAMA LLC
Other - Org Name:DOTHAN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3993
Mailing Address - Street 1:PO BOX 1964
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1964
Mailing Address - Country:US
Mailing Address - Phone:334-794-5000
Mailing Address - Fax:
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-794-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J446Medicare ID - Type UnspecifiedPHYSICIAN PRACTICE