Provider Demographics
NPI:1265687818
Name:CARY CREEK MEDICAL PC
Entity Type:Organization
Organization Name:CARY CREEK MEDICAL PC
Other - Org Name:BEAUREGARD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-737-5557
Mailing Address - Street 1:7667 ALABAMA HWY 51 SUITE B
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36804
Mailing Address - Country:US
Mailing Address - Phone:334-737-5557
Mailing Address - Fax:334-767-5646
Practice Address - Street 1:7667 ALABAMA HWY 51 SUITE B
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36804
Practice Address - Country:US
Practice Address - Phone:334-737-5557
Practice Address - Fax:334-767-5646
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARY CREEK MEDICAL, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-24
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO866261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51595037OtherBCBS
ALF05084Medicare UPIN
AL510G700458Medicare PIN