Provider Demographics
NPI:1851602981
Name:CULLMAN PRIMARY CARE, PC
Entity Type:Organization
Organization Name:CULLMAN PRIMARY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-739-0801
Mailing Address - Street 1:503 CLARK ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-1921
Mailing Address - Country:US
Mailing Address - Phone:256-739-0801
Mailing Address - Fax:256-739-0027
Practice Address - Street 1:1406 WALL ST
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-6011
Practice Address - Country:US
Practice Address - Phone:256-736-2856
Practice Address - Fax:256-736-2867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CULLMAN PRIMARY CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-23
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529928340Medicaid
ALE869Medicare PIN