Provider Demographics
NPI:1568748242
Name:FORT MITCHELL CLINIC PC
Entity Type:Organization
Organization Name:FORT MITCHELL CLINIC PC
Other - Org Name:PREFERRED MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:L
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:334-664-0463
Mailing Address - Street 1:3700 S RAILROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-2993
Mailing Address - Country:US
Mailing Address - Phone:334-664-0463
Mailing Address - Fax:334-664-0466
Practice Address - Street 1:2 GILMORE RD
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:AL
Practice Address - Zip Code:36856-4411
Practice Address - Country:US
Practice Address - Phone:334-664-0463
Practice Address - Fax:334-664-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207L00000X
ALMD7157207Q00000X
ALMD26862208000000X, 261Q00000X
AL013962261QR1300X
AL1-129486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL133816Medicaid
AL133816Medicaid