Provider Demographics
NPI:1982685178
Name:CULLMAN PRIMARY CARE, PC
Entity Type:Organization
Organization Name:CULLMAN PRIMARY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOSTICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-734-3141
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:256-739-1759
Mailing Address - Fax:256-739-0027
Practice Address - Street 1:105 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-3511
Practice Address - Country:US
Practice Address - Phone:256-734-3141
Practice Address - Fax:256-734-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X
AL01D0300133291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000040933OtherMEDICARE GROUP ID
AL000040933Medicaid
AL000040933Medicare ID - Type Unspecified
AL000040933Medicaid