Provider Demographics
NPI:1750457602
Name:SPECIALTY MEDICAL CENTERS LLC
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIASE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:205-507-1264
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-0278
Mailing Address - Country:US
Mailing Address - Phone:205-507-1264
Mailing Address - Fax:205-507-1266
Practice Address - Street 1:535 JACK WARNER PKWY NE
Practice Address - Street 2:G-2
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5751
Practice Address - Country:US
Practice Address - Phone:205-507-1264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529926930Medicaid
AL529926930Medicaid
ALP000350358Medicare PIN
ALK717Medicare ID - Type UnspecifiedMEDICARE GROUP #