Provider Demographics
NPI:1568901742
Name:PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLC
Entity Type:Organization
Organization Name:PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENEFICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-754-8723
Mailing Address - Street 1:3113 LAWTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3531
Mailing Address - Country:US
Mailing Address - Phone:888-829-8550
Mailing Address - Fax:
Practice Address - Street 1:126 CLINIC DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1980
Practice Address - Country:US
Practice Address - Phone:888-829-8550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAXCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty