Provider Demographics
NPI:1598822272
Name:DOTHAN INTERNAL MEDICINE
Entity Type:Organization
Organization Name:DOTHAN INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-699-2004
Mailing Address - Street 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3001
Mailing Address - Country:US
Mailing Address - Phone:334-699-2004
Mailing Address - Fax:334-699-2006
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:SUITE 105
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-699-2004
Practice Address - Fax:334-699-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00020759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51522252OtherBCBS
AL529919960Medicaid
ALG57973Medicare UPIN
ALJ961Medicare PIN