Provider Demographics
NPI:1609879220
Name:CULLMAN COUNTY MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:CULLMAN COUNTY MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHYSICIAN PRACTICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:JOCHUM
Authorized Official - Last Name:HICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-736-5328
Mailing Address - Street 1:1910 CHEROKEE AVE. SW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055
Mailing Address - Country:US
Mailing Address - Phone:256-739-3500
Mailing Address - Fax:256-775-6119
Practice Address - Street 1:1910 CHEROKEE AVE SW
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-5502
Practice Address - Country:US
Practice Address - Phone:256-739-3500
Practice Address - Fax:256-736-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907580Medicaid
ALJ690Medicare PIN
ALI458Medicare PIN
AL529907580Medicaid