Provider Demographics
NPI:1508043662
Name:SUMMERDALE FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:SUMMERDALE FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-989-9400
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:SUMMERDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36580-0600
Mailing Address - Country:US
Mailing Address - Phone:251-989-9400
Mailing Address - Fax:251-989-2090
Practice Address - Street 1:109 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:SUMMERDALE
Practice Address - State:AL
Practice Address - Zip Code:36580
Practice Address - Country:US
Practice Address - Phone:251-989-9400
Practice Address - Fax:251-989-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051555997Medicaid
AL051555997Medicaid
AL051555997SANMedicare PIN