Provider Demographics
NPI:1407976624
Name:DODGE CITY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:DODGE CITY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BUCCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:256-287-2345
Mailing Address - Street 1:PO BOX 1208
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-1208
Mailing Address - Country:US
Mailing Address - Phone:256-287-2345
Mailing Address - Fax:
Practice Address - Street 1:561 AL HIGHWAY 69 S
Practice Address - Street 2:SUITE B
Practice Address - City:HANCEVILLE
Practice Address - State:AL
Practice Address - Zip Code:35077-3403
Practice Address - Country:US
Practice Address - Phone:256-287-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD27216261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care