Provider Demographics
NPI:1437206885
Name:STEPHEN R BRANDT MD GROUP
Entity Type:Organization
Organization Name:STEPHEN R BRANDT MD GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-774-1412
Mailing Address - Street 1:633 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1836
Mailing Address - Country:US
Mailing Address - Phone:334-774-1412
Mailing Address - Fax:334-774-1825
Practice Address - Street 1:105 E WATTS ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2511
Practice Address - Country:US
Practice Address - Phone:334-393-5437
Practice Address - Fax:334-393-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16264261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL167510Medicaid