Provider Demographics
NPI:1942531959
Name:JACK M ENGLERT MD PC
Entity Type:Organization
Organization Name:JACK M ENGLERT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:ENGLERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-517-1507
Mailing Address - Street 1:101 BOB WALLACE AVE SW
Mailing Address - Street 2:SUITE D
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3847
Mailing Address - Country:US
Mailing Address - Phone:256-517-1507
Mailing Address - Fax:256-517-1508
Practice Address - Street 1:101 BOB WALLACE AVE SW
Practice Address - Street 2:SUITE D
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3847
Practice Address - Country:US
Practice Address - Phone:256-517-1507
Practice Address - Fax:256-517-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL15840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE87616OtherUPIN
AL051503250OtherMEDICARE PTAN