Provider Demographics
NPI:1568571602
Name:FAMILY PRACTICE OF JACKSONVILLE PC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF JACKSONVILLE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEWAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:VERMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-435-3035
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:1881 HWY 21 SOUTH
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265
Mailing Address - Country:US
Mailing Address - Phone:256-435-3035
Mailing Address - Fax:256-435-9111
Practice Address - Street 1:1881 HWY 21 SOUTH
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265
Practice Address - Country:US
Practice Address - Phone:256-435-3035
Practice Address - Fax:256-435-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7306207K00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01D0689490OtherCLIA
C72876Medicare UPIN
AL000006481Medicare PIN