Provider Demographics
NPI:1518170133
Name:WOODSTOCK MEDICAL, LLC
Entity Type:Organization
Organization Name:WOODSTOCK MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-236-1300
Mailing Address - Street 1:409 E 10TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-4781
Mailing Address - Country:US
Mailing Address - Phone:256-236-1300
Mailing Address - Fax:256-236-0254
Practice Address - Street 1:409 E 10TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4781
Practice Address - Country:US
Practice Address - Phone:256-236-1300
Practice Address - Fax:256-236-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12210208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000001769Medicare PIN
ALC70709Medicare UPIN