Provider Demographics
NPI:1952472607
Name:WETUMPKA FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:WETUMPKA FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:334-567-7850
Mailing Address - Street 1:73970 TALLASSEE HWY
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092
Mailing Address - Country:US
Mailing Address - Phone:334-567-7850
Mailing Address - Fax:334-567-7866
Practice Address - Street 1:73970 TALLASSEE HWY
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092
Practice Address - Country:US
Practice Address - Phone:334-567-7850
Practice Address - Fax:334-567-7866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C78734Medicare UPIN