Provider Demographics
NPI:1558616029
Name:REALM INCORPORATED
Entity Type:Organization
Organization Name:REALM INCORPORATED
Other - Org Name:NATHANAEL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-702-8872
Mailing Address - Street 1:PO BOX 8307
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36304-0307
Mailing Address - Country:US
Mailing Address - Phone:334-702-8872
Mailing Address - Fax:334-702-8957
Practice Address - Street 1:1435 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1311
Practice Address - Country:US
Practice Address - Phone:334-702-8872
Practice Address - Fax:334-702-8957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO190261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE01167Medicare UPIN
AL000033060Medicare PIN