Provider Demographics
NPI:1659518553
Name:MEDICAL EAST OF DECATUR INC
Entity Type:Organization
Organization Name:MEDICAL EAST OF DECATUR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:256-432-2822
Mailing Address - Street 1:2941 POINT MALLARD PKWY SE STE N
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-5760
Mailing Address - Country:US
Mailing Address - Phone:256-432-2822
Mailing Address - Fax:256-432-2825
Practice Address - Street 1:2941 POINT MALLARD PKWY SE
Practice Address - Street 2:STE N
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-5716
Practice Address - Country:US
Practice Address - Phone:256-432-2822
Practice Address - Fax:256-432-2825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
AL1105407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty