Provider Demographics
NPI:1790840775
Name:BOAZ FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:BOAZ FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:256-840-5800
Mailing Address - Street 1:122 N SNEAD ST
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1763
Mailing Address - Country:US
Mailing Address - Phone:256-840-5800
Mailing Address - Fax:256-840-5600
Practice Address - Street 1:122 N SNEAD ST
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1763
Practice Address - Country:US
Practice Address - Phone:256-840-5800
Practice Address - Fax:256-840-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO287261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51504831OtherBLUE CROSS BLUE SHIELD
AL51504831OtherBLUE CROSS BLUE SHIELD