Provider Demographics
NPI:1598905101
Name:CONNIE A. CHANDLER, MD
Entity Type:Organization
Organization Name:CONNIE A. CHANDLER, MD
Other - Org Name:OZARK MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-774-5116
Mailing Address - Street 1:145 KATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1976
Mailing Address - Country:US
Mailing Address - Phone:334-774-5116
Mailing Address - Fax:334-774-6848
Practice Address - Street 1:145 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1976
Practice Address - Country:US
Practice Address - Phone:334-774-5116
Practice Address - Fax:334-774-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00004122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000001123Medicaid
AL000001123Medicaid