Provider Demographics
NPI:1417019670
Name:RHEUMATOLOGY ASSOCIATES OF DOTHAN IDTF
Entity Type:Organization
Organization Name:RHEUMATOLOGY ASSOCIATES OF DOTHAN IDTF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARKS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-9564
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-9564
Mailing Address - Fax:334-671-8907
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-9564
Practice Address - Fax:334-671-8907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RHEUMATOLOGY ASSOCIATES OF DOTHAN, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL141102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty