Provider Demographics
NPI:1629491451
Name:PICKENS COUNTY PRIMARY CARE PC
Entity Type:Organization
Organization Name:PICKENS COUNTY PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-792-6701
Mailing Address - Street 1:108 4TH AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:REFORM
Mailing Address - State:AL
Mailing Address - Zip Code:35481-8018
Mailing Address - Country:US
Mailing Address - Phone:205-375-6251
Mailing Address - Fax:205-375-9064
Practice Address - Street 1:108 4TH AVE SW STE A
Practice Address - Street 2:
Practice Address - City:REFORM
Practice Address - State:AL
Practice Address - Zip Code:35481-8018
Practice Address - Country:US
Practice Address - Phone:205-375-6251
Practice Address - Fax:205-375-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL162102Medicaid
AL102G702189Medicare PIN