Provider Demographics
NPI:1255609301
Name:SOUTHERN FAMILY MEDICINE
Entity type:Organization
Organization Name:SOUTHERN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-840-4571
Mailing Address - Street 1:P.O. BOX 11407
Mailing Address - Street 2:DEPT# 2069
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2069
Mailing Address - Country:US
Mailing Address - Phone:256-840-4571
Mailing Address - Fax:256-840-4534
Practice Address - Street 1:2367 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5910
Practice Address - Country:US
Practice Address - Phone:256-840-4571
Practice Address - Fax:256-840-4534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL MEDICAL CENTER SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty