Provider Demographics
NPI:1235590001
Name:MEDCENTER FAYETTE, LLC
Entity Type:Organization
Organization Name:MEDCENTER FAYETTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:POSEY
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-330-1707
Mailing Address - Street 1:3909 MCFARLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-2838
Mailing Address - Country:US
Mailing Address - Phone:205-330-1707
Mailing Address - Fax:205-333-0782
Practice Address - Street 1:122 17TH CT NE
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1353
Practice Address - Country:US
Practice Address - Phone:205-330-1707
Practice Address - Fax:205-333-0782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUSCALOOSA MEDCENTER NORTH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-08
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
AL12135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL12135OtherMD LICENSE