Provider Demographics
NPI:1245398304
Name:FAMILY MEDICINE OF SARDIS PC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF SARDIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-593-9999
Mailing Address - Street 1:PO BOX 1049
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-2201
Mailing Address - Country:US
Mailing Address - Phone:256-593-9999
Mailing Address - Fax:256-593-9141
Practice Address - Street 1:1180 SARDIS DR
Practice Address - Street 2:
Practice Address - City:SARDIS CITY
Practice Address - State:AL
Practice Address - Zip Code:35956-2139
Practice Address - Country:US
Practice Address - Phone:256-593-9999
Practice Address - Fax:256-593-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALJ840Medicare PIN