Provider Demographics
NPI:1285832733
Name:SMITH LAKE URGENT CARE, LLC
Entity Type:Organization
Organization Name:SMITH LAKE URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-387-7555
Mailing Address - Street 1:1280 SUMMIT DR.
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-0102
Mailing Address - Country:US
Mailing Address - Phone:205-387-7555
Mailing Address - Fax:205-387-7551
Practice Address - Street 1:6610 CURRY HWY
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35503-5664
Practice Address - Country:US
Practice Address - Phone:205-387-7555
Practice Address - Fax:205-387-7551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529932857Medicaid
510G700030Medicare PIN