Provider Demographics
NPI:1932137924
Name:LODEWICK DIABETES CORPORATION
Entity Type:Organization
Organization Name:LODEWICK DIABETES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-747-8991
Mailing Address - Street 1:3918 MONTCLAIR RD STE 217
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2418
Mailing Address - Country:US
Mailing Address - Phone:205-933-7881
Mailing Address - Fax:205-785-2864
Practice Address - Street 1:3918 MONTCLAIR RD STE 217
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35213-2418
Practice Address - Country:US
Practice Address - Phone:205-933-7881
Practice Address - Fax:205-785-2864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00015124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL78865OtherAETNA HEALTH
AL0051078865OtherBLUE CROSS BLUE SHIELD
AL529804240Medicaid
AL529804240Medicaid